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       SAMUEL   S.   &  WILLIAM  WOOD,


                261 PEARL STREET, NEW YORK,

Have an extensive assortment of books in the various departments of Litera-
ture, which they offer at low prices.  Amongst them are the following works
on Medicine, Natural History, Agriculture, &c.  to which they are constantly
adding the new publications as they appear.

COOPER'S FIRST LINES OF THE THEORY  AND PRACTICE OF  SUR-
  GERY, including the  principal operations.   With Notes and Additions, by Willard
  Parker, M.D., Professor  of Surgery in the College  of Physicians and  Surgeons in
  the University of the State of New York. &c. 2 vols.
MOREAU'S PRACTICAL TREATISE ON MIDWIFERY, edited by Paul B. God-
  dard, M.D.  80 plates, quarto.
PANCOAST'S OPERATIVE SURGERY.  80 plates, quarto.
FOX'S NATURAL HISTORY  AND  DISEASES  OF THE  HUMAN  TEETH,
  23 plates, quarto.
dUAIN'S  ANATOMICAL PLATES OF THE  ARTERIES OF THE  HUMAN
  BODY.  With Notes, &c., by J. PANCO AST, M.D.  34 coloured plates, quarto.
QUAIN'S  ANATOMICAL PLATES OF THE ARTERIES  AND NERVES,  with
  Notes, &c., by J. Pancoast, M.D.  50 coloured plates, quarto.
BELL  (CHARLES) ON  INJURIES OF THE SPINE AND THIGH BONE.—
  9 plates, quarto.
DERMOTT'S ILLUSTRATIONS  OF  THE  ARTERIES CONNECTED WITH
  ANEURISM.—Plates size of life, coloured.
WOODVILLE AND HOOKER'S MEDICAL BOTANY, containing  systematic and
  general descriptions, with plates of Medicinal Plants, Indigenous ana Exotic, &c. &c.
  310 coloured plates, quarto.
BIGELOW'S AMERICAN MEDICAL  BOTANY, 3 vols. 8vo.   60 coloured plates.
Abernethy's Surgical Works, 2 vols.
Accum's Chemical Amusement
Adams on Morbid Poisons.
Alibert on Malignant Intermittents.
Alison's Outlines of Pathology.
Andral on the Blood.
Armstrong** Art of Preserving Health, a
  Poem.
Armstrong's Life and Medical  Opinions,
  2 vols.
Assalini on the Plague.
Atkin's Medical and Surgical Cases.
Bartlett's Philosophy of Medical Science.
BarwelFs Infant Treatment.
Begin on Application of Physiological Doc-
  trine to Surgery.
Bell on Nervous System.
Bell's (Benjamin) System of Surgery, 5
  vols.
Black's Clinical Reports.
Boyer on Surgical Diseases, 2 vols,
Brown's Elements of Medicine.
Burke s Dispensing Chemist's Assistant.
Campbell on Puerperal Fever.
Carlisle on Means of Preserving Health.
Carpenter's Essays on Articles of Materia
  Medica.
Castle on Poisons, 21 coloured plates.
Castle's Introduction to Medical Botany.
Chailly's Midwifery, edited  by  Professor
  Bedford.
Chapman on Thoracic and Abdominal Vis-
  cera.
Chapman's Therapeutics, 2 vols.
Chavasse's Advice to Wives.
Chavasse's Advice to Mothers.
Cheselden's Engravings of Human Bones.
Cheyne on Croup.
------on Preservation of Health.
Combe on Mental Derangement.
Condic on Diseases of Children.
Conolly on Indications of Insanity.
Cooper's (Sir Astley)  Principles and Prac-
  tice of Surgery, 3 vols. 
 Corvisart on Diseases of the Heart.
 Cullen's Practice of Physic.
 Curtis on Preservation of Health.
 -----on the Ear
 _____& Lillie's Homoeopathic Practice
 Cutbush on Health of Soldiers and Sailors.
 Cyclopedia of Anatomy and Physiology.
'---------of Practical Surgery.
 Darrach's Anatomy of the Groin.
 Davies on Use of Iodine.
 Davis' Obstetric Medicine, 2 vols.
 Denmans  Aphorisms on  Practical Obste-
   tricy.
 Desruelles on Venereal.
 Dewees on Difficult Parturition.
 Dickson's Fallacies of the Faculty.
 Dix on Strabismus.
 Fowne's Chemical Prize Essay.
 Frick on Diseases of the Eye.
 Gallup on Epidemic Diseases.
 iGoupil's Exposition of the New Medical
   Doctrine.
 Greenhow on Cholera.
 Report of French Academy on Cholera.
 Gregory on Change of Climate.
 Guthrie on Diseases and Injuries of Arteries.
 -------on Operative  Surgery of the Eye.
 -------on Urinary and Sexual Organs.
 Guy's Medical Jurisprudence.
 Haller's Physiology.
 Harris  on  Characteristics of Teeth and
   Gums.
 Harrison on Nervous System.
 Harrison's Anatomy of the Arteries.
 Hastings on Inflammation.
 Hawkins on Rheumatism.
 Heberden on Diseases of Children.
 Home on Ulcers on the Legs, &c.
 Home Book of Health and Medicine.
 Hope's Illustrations  of Morbid  Anatomy,
   coloured plates.
 Howship on Appearances, &c. of Surgical
   Disease.
 Hufeland's Practice of Medicine.
 Jackson on Fevers of Jamaica.
 James' Merriman on Difficult Parturition.
 Jeffray on the Heart and Foetus.
 Johnson on Civic Life, Sedentary Habits,
   &c.
 ------  on Tropical Climates.
 Johnston on Urinary Gravel and Stone.
 Jones on Haemorrhage.
 Kay on Asphyxia.
 Koecker on Diseases  of the Jaws.
 Lady's Medical Pocket Book.
 Lavater's Physiognomy, 400 engravings.
 Lee's Midwifery.
 ---- Chemical Diagrams.
 ---- Celsus, Latin and English.
 Leo-Wolf on Homoeopathic Medicine.
 Liebig's Familiar Letters on Chemistry.
 London Chemical Pocket Book.
 ------Surgical Pocket Book.
 Lucas' Anatomical Description of Arteries.
 Mackintosh's Practice of Medicine.
 Maclean on Hydrothorax.
 Macnish's Philosophy of Sleep.
 Magendie's Physiology, edited by Professor
   Revere.
 Male's Juridical Medicine.
 Mayo on Organs of Digestion.
 Mayo's Outlines of Pathology.
 Michell on Ergot of Rye.
 Monro's Anatomy of the Bones and Nerves.
 Mutter on Club Foot.
 Neligan's Medicines, their Uses, Mode  of
   Administration,  &c.
 Norwood's Family Medical Library.
 Nurineley on Erysipelas.
 Parib' Medical Chemist%r.
 Paris and Fonblanque's Medical Jurispru-
   dence, 3 vols.
 Parnell's Applied Chemistry.
 Paul on Diseases of the Lower Bowel.
 ----on Ringworm.
 Pettigrew's Medical Superstitions.
 Philip on Means of Preserving Health.
 Pinney on Health and Long Life.
 Prichard's Physical History of Mankind, 4
   vols.
 Priessnitz's Water Cure.
 Ramadge on Consumption.
 Ramsden on the Testicle.
, Ray's Medical Jurisprudence of Insanity.
 Ratier's Medical Guide to Paris.
 Reid on Nervous Affections.
 Rennie's Supplement to Pharmacopoeias.
 Robertson's Medical Conversations, 2 vols.
 Russell's Invalid's Friend.
 Saunders on the Ear.
 --------on the Eye.
 Sawyer on Fever.
 Shew's Hand-Book of Hydropathy.
 ------Water Cure for Ladies.
 Smellie's Anatomical Plates of Midwifery1.
 Smith on Typhus  Fever.
 Solly on the Brain.
 Spallanzani on Respiration.
 Spender on Ulcerous Diseases of the Leg.
 Spooner's Guide to Sound Teeth.
 Stevenson on Cataract.
 Struve on Suspended Animation.
 Thenard on Chemical Analysis.
 Thorburn's Bedside Medicine and General
   Pathology.
 Transactions  of Medical  Society  of New
   York, 3 vols.
 Trotter on Nervous Temperament.
 Tumbull on Diseases of the Eye and Ear.
 Ure's Materia Medica.
 ----Dictionary of Arts, &c.
 Velpeau's Surgical Anatomy, 2 vols.
 --------Operative Surgery, 3 vols.
 Watson's Practice of Physic.
 Webb's Philosophy of PJedicine.
 Whitlaw on Inflammation, &c.
 Willan on Cutaneous Diseases.
 Wilson on Action of Morbid Sympathies.
 ------on Gout and Rheumatism.
 Wright on Quackery in Medicine. 
AberCrombic on Brain and Spinal Cord.
---------- on Stomach.
   ■  ■  ----on Intellectual Powers.
----------Philosophy of Moral Feelings.
Abemethy's Surgical Observations.
----------Lectures on Surgery.
Ackerly on Children.
Alcott's Young Mother.
------ Mother's Medical Guide.
Amussat on Retention of Urine.
Anatomical Examinations.
Anderson's Surgical Anatomy.
Andrtd's Medical Clinic, 3 vols.
-------Diseases of Abdomen.
-------     do.     Chest.
-------     do.     Encephalon.
Aretjeus on ^Etiology, and Schill  on  Seme-
    iology.
Armstrong on Puerperal Fever, Consump. &c.
Armstrong, Gordon, Hay, and Lee on Puer-
    peral  Fever.
Armstrong's Practice of Medicine, 2 vols.
Arnott's Physics.
Ashwell on Diseases of Women.
AveriU's Operative Surgery.
Baillie's Morbid Anatomy.
Bakewell's Geology.
Bancroft on Fever.
Bard's  Midwifery.
Bartlett on Typhoid and Typhus Fever.
Barton's Materia Medica and Botany,  2 vols.
Bateman on Cutaneous Diseases.
Baudelocque on Puerperal Peritonitis.
Bayle's Anatomy.
Bayle and Hollard's Anatomy.
Beach's PVactice of Medicine.
Beaumont on Gastric Juice.
Beche's Geological Manual.
Beck's  Medical Jurisprudence, 2 vols.
------Chemistry.
Beclard's General Anatomy.
Beddoes on Calculus, Consumption, &c.
Begin's Therapeutics.
Belinaye on Lithotripsy.
Bell's Engravings of Arteries,
------------------Nerves.
-----------------Bones.
-----Materia Medica.
-----Anatomy, 3 vols.
-----Institutes of Surgery.
Bell on Teeth.
---on Mechanism of the Hand.
---on Baths and Mineral  Waters.
---on Wounds.
---on Venereal.
---on Regimen, and Longevity.
Berzelius on Kidneys and Urine.
Bichat  on  Life and Death.
-----on  Membranes.
Bichat's Anatomy, 4 vols.
-------Pathology.
Bigelow's  Technology.
--------Medical Botany, 3 vols.
BUlard  on  Diseases of Infants.
Billings' Principles of Medicine.
Blackall on Dropsy.
Blacklock  on Sheep.
Blake's Botany.
B lane's Medical Logic.
Blundell's Midwifery.
--------  Diseases of Women.
Boisseau on Fever.
Borreman's Neurology, on canvass.
Bostock's Physiology.
Boston Medical Magazine, 3 vols.
Brande's Encyclopedia of Science.
Brewster's Optics.
---------Edinburgh Encyclopedia, 18 vols.
Bricheteau's Medical Clinics.
Bridgeman's Gardener's Assistant.
Bridgewater Treatises, 7 vols.
Brigham on Brain, Spinal Gord, &c.
-------on Influence of Religion on Health.
Brodie on  Urinary Organs.
-----on the  Joints.
Broussais' Phlegmasioe, 2 vols.
Buchan's Domestic Medicine.
Buckland's Geology, 2 vols.
Buckminster's Practical Farmer.
Buel's Farmer's Companion.
Buist's Flower Garden Directory.
Burne on Constipation.
Burns on Inflammation.
Bush on the Rectum, 2 vols.
Carmichael on VenereaL
Carpenter's Human Physiology.
----------Vegetable  do.
Castle's Manual of Surgery.
Cattle ;  their Breeds, Managt. and Diseases.
Cazenave on Cutaneous Diseases.
Chalmers and Kidd on Man.
Chaptal's Agricultural Chemistry.
Chase on Hernia.
Cheselden's Anatomy.
Child's Family Nurse.
Chitty's Medical Jurisprudence.
Churchill on Diseases of Females.
Churchill's Midwifery.
Civiale on Stone and Davis on Hydrocephalus,
Clark on Consumption.
-----on Climate, and Gibert on Blood.
Clarke on the Mulberry.
Cleaveland's Mineralogy.
Coates' Popular Medicine.
------Physiology.
Colhoun's Prout on Diabetes, Calculus, &c
---------on  Suspended Animation.
Colles' Surgical Anatomy.
------on Venereal.
Collins' Midwitery.
Combe on Constitution of Man.
------on Digestion.
------on Infancy.
------on Phrenology.
Comstock's Chemistry.
----------Natural Philosophy.
----------Botany.
----------Geology.
----------Mineralogy.
----------Physiology.
Cooke on White Mustard Seed.
-----on Nervous Diseases.
Cooke's Morgagni  on Causes  of Disease*
     2 vols. 
 Cooper on  Spermatic Cord, Rowland  on
     Neuralgia, Osborne on Dropsy, Syme
     on Rectum,  and Clendenning  on the
     Heart,—all in one vol.
 Cooper on Dislocations.
 ------on Hernia.
 Cooper and Travers' Surgical Essays.
 Cooper's Surgical Dictionary.
 -------Lectures on Surgery.
 Copland's Dictionary of Medicine.
 Coster's Physiological Practice.
 ------- Manual of Surgical Operations.
 Coulson on Bladder and Prostate Gland.
 Cox on Bones, Ligaments, &c.
 ---on Insanity.
 Coxe's Dispensatory.
 Craigie's Anatomy.
 Cultivator, 7 vols.
 Curling on Tetanus.
 Cutler on Bandages.
 Cyclopedia of Practical Medicine, 4 vols.
 Dana's Mineralogy.
 ------Muck Manual.
 Darwin's Zoonomia, 2 vols.
 Davidson and Hudson on Fever.
 Davis on Hydrocephalus.
 Davy's Physiological Researches.
 Dendy on Dreams.
 ------on Skin in Infancy.
Desault's Surgery, 2 vols.
 Deslandes' Manhood.
 Detmold on Club Foot.
 Dewees' Midwifery.
-------Practice of Phvsics,
-------on Females.;
-------on Children.
Dick on Digestion.
 Doane's Surgery Illustrated.
 Dorsey's Surgery, 2 vols.
-------Cooper, 2 vols.
 Downing's Landscape Gardening.
---------Cottage Residences.
Druitt's Modern Surgery.
Dublin Dissector.
Dublin Practice of Midwifery.
Ducamp on Retention of Urine.
 Duffin on Deformity of the Spine.
Dunglison's Physiology, 2 vols.
----------New  Remedies.
----------Practice, 2 vols.
----------Therapeutics, 2 vols.
----------Medical Dictionary.
----------Hygiene.
----------Medical Student.
Dunsford's Advantages of Homoeopathy.
Duparcque on Uterus.
Dupuytren's Lectures on Surgery.
Eaton's Manual of Botany.
Eberle on Children.
Eberle's Practice of Medicine, 2 vols.
-------Therapeutics.
-------Notes.
Edward's Surgical Anatomy.
--------Anatomy and Physiology.
Edwards and Vavasseurs Materia Medica.
Edwards on Life.
Ellis' Medical Formulary.
 Encyclopedia Americana, 13 vols.
 Evanson and Maunsell on Children
 Ewell's Medical Companion.
 Faithorn on Liver.
 Faraday's Chemical Manipulations.
 Farrar's Optics.
 —------Astronomy.
 Ferguson on Puerperal Fever.
 Ferguson's Practical Surgery.
 Fessenden's American Gardener.
 ----------Complete Farmer.
 Fisher on the Vine.
 ------on Small Pox.
 Fitch on  Consumption.
 Fitch's Dental Surgery.
 Flourens sur  la  Generation, I'Ovologia,  et
     l'Embryologie.
 Fordyce on Fever.
 Forry on Climate  of the United States.
 Francis' Denman's Midwifery.
 Freckleton's Pathology.
 Gall's Manual of Phrenology.
' Gallup's Institutes of Medicine, 2 vols.
 Gerhard on the Chest.
 Gibson's  Surgery, 2 vols.
 Goddard's Plates of Arteries.
 ---------do     Nerves.
 Godman's American Natural History, 2 vols.
 ---------Discourses.
 ---------Anatomical Investigations.
 Goldsmith's Animated Nature, 4 vols.
 Gooch on Diseases of Females.
 Gooch's Midwifery.
 Goods' Book of Nature.
 ------Study of Medicine, 2 vols.
 Graham's Chemistry.
 Graves' Clinical Lectures.
 Granville on Counter Irritation, and Morgan's
     Surgery.
 Gray's Operative Chemist.
 ------Elements of Chemistry.
 ------Pharmacy.
 ------Botanical Text Book.
 Green on Diseases of the Skin.
 Gregory's Practice of Physic, 2 vols.
 Gross' Pathological Anatomy, 2 vols.
 -----Anatomy, &c. of Bones, and Joints.
 Guthrie on Fractures, Christison on the Kid-
     neys, and Evers' Comparative Anatomy.
 Hahnemann's Homoeopathic Medicine.
 Hale's Flora's Interpreter.
 Halford's (Sir Henry) Essays.
 Hall on the Blood.
 ----on Nervous System.
 ----on Diagnosis.
 ----on Diseases of Females.
 Hall's Practice of Medicine.
 Halsted on Dyspepsia.
 Hamilton on Purgatives.
 --------on Mercury.
 Hare's Chemistry.
 Harris' Dental Surgery.
 Harris on Maxillary Sinus.
 Hatin's Obstetrics.
 Heberden's Commentaries.
 Hecker's  Epidemics of Middle Ages
 Hennen's Military Surgery. 
      FIRST LINES




         OF THE





THEORY  AID PRACTICE




          OF





    SURGERY. 
 
THE
FIRST  LINES
OF THE
THEORY  AID   PRACTICE
     SURGERY;
            INCLUDING
THE PRINCIPAL  OPERATIONS
        BY SAMUEL£OOPER,
SENIOR SURGEON TO UNIVERSITY COLLEGE HOSPITAL, AND PROFESSOR OF
        SURGERY IN THE SAME COLLEGE, ETC.
     WITH NOTES AND  ADDITIONS,

       BY WILLARD PARKER, M. D.,
PROFESSOR OF SURGERY IN THE COLLEGE OF PHYSICIANS AND SURGEONS
   IX THE UNIVERSITY OF THE STATE OF NEW YORK, ETC., ETC.
        IN TWO VOLUMES.


          V0L- "•    [fiffj^
  Fourth American, from the Seventh London Edition *J£5 rp * -O s;_ /


         NEW YORK:
SAMUEL  S. AND WILLIAM WOOD,
        261 Pearl Street.
1S44. 
r\  r) n € x,

CT7g-fi
Entered according to Act of Congress, in the year 1844, by
       SAMUEL S. AND WILLIAM  WOOD,
in the Clerk's office of the District  Court of the Southern
               District of New York. 
CONTENTS.
Acute inflammation of the Testicle 214
Amaurosis or Gutta Serena  .     88
Atrophy of the Testicle   .    .217
Bronchocele       .    .     .    133
Caries of the Spine Scrofulous  .  170
Cancer of the Lips     .     .    116
Cancer of the Penis .    .    .  242
Catarrhal Ophthalmia   .     .     57
Catarrho-Rheumatic Ophthalmia   71
Cataract          .    .     .     93
Catheters      .    .    .    .264
Circocele    ....    238
Compression of the Brain .    .   24
Concussion of the  Brain     .     28
Corneitis Scrofulous ...   72
Choroiditis and Retinitis     .     77
Chordee.....285
Chronic enlargement of the Testicle 218
Chronic Mammary Tumor     .  149
Closure of the Pupil and Formation
  of an Artificial Pupil .     .     85
Cystitis.....286
Diseases of the Antrum .     .    112
    "     "    Breast     .    .  141
          «    Ear    .         102
    <<     "    Eye and its appen-
  dages  .    .     .     ••   34
          «    Eyelids .     .     46
    «     "    Genital Organs  .  213
    "     "    Gums   .     .    121
    «     "    Prostate Gland  .  244
    «     "    Scrotum      .    240
    «     ««    Tongue    .    .117
          «    Tonsils .     .    120
Dislocations  of the Lower Jaw  .  361
            «   Clavicle   .    364
     "     «   Humerus    .  366
            "   Elbow     .    374
            «   AVrist  .    .  376
     "     "    Bones of the Car-
  pus                     »    378
Dislocations of the Thumb
                Vertebrae
379
381
382
384
385
392
393
395
395
397
                Head   .
                Ribs  .
                Hip
                Patella
                Knee
                Fibula
                Ankle Joint
                Astragalus
EctropiumorEversionofthe Eyelids 49
Egyptian or Purulent Ophthalmia  59
Emphysema .    .     .     .    139
Entropium     ....   52
Encysted tumors of the Eyelids    49
Encanthis      ....   37
Epulis or Excrescences from the
  Gums     ....    122
Excoriations and Ulcerated Fissures
  in the Nipple    .         .142
Fractures of the Skull  .          16
    "    "     "  Treatment   19
    "    "   Ossa Nasi   .    307
Fractures of the Malar and Supe-
  rior Maxillary Bones  .     .  308
    "    <:   Inferior Maxillary
  Bone      ....    308
              Inferior Maxillary
Bone Compound
  «    "     Spine
pus, etc,
Sternum
Ribs
Clavicle
Scapula .
Humerus
Radius  .
Ulna  .
Carpus Metacar-

Pelvis .
Femur  .
311
312
316
319
321
326
329
333
334

338
33 °.
33d 
X
CONTENTS.
Fractures of the Neck of the Femur 345
               Patella  .    .   355
               Tibia .     .     359
               Fibula  .    .   360
          «    OsCalcis   .     361
Fistula in Ano Abscesses .    .290
Fistula Lachrymalis   .     .      38
Fissura Ani    ....   304
Foreign bodies in the  Oesophagus 128
Fungous  tumors  in  the  Dura
  Mater  .....    33
Granular Conjunctiva     .    .   54
Glaucoma    ....      78
Gleet, treatment of .    .    .   282
Gonorrhoea  ....     274
    "     treatment of  .    .   279
Hare Lip     ....     114
Haematocele   .    .    .    .236
Hemeralopia or Night Blindness    92
Hernia Cerebri or Encephalocele    31
Hernia.....178
   «   Reducible  .    .     .     181
   "   Irreducible  .     .    .183
   "   Strangulated   .     .     184
   "   Inguinal or Bubonocele .   186
   "   Inguinal Congenital  .     207
   "   Femoral or Crural .    .196
   "   of the Coecum and  Colon   209
   «'  Umbilical or Exomphalos  210
   «   Vervi.ul    .    .     .     211
   «   of the Bladder Cystocele   212
Hordeolum, or Stye    .     .      48
Hydatids of the Testicle   .    .   221
Hydrocele   .     .    .     .     2£7
   "    Treatment       .    .   230
   "    Congenital    .     .     234
   "   of Spermatic  cord     .   235
Hypopium  .                    80
Hydrophthalmia   .     .    .87
Hydatid Tumors of the Breasts   148
Hypertrophy of the Breasts    .   148
Incontinence of Urine .     .     272
Injuries of the Head      .    .    13
Iritis.....7;j
Irritable Testicle   .     .    .   2-21
Irritable Tumor of the Breast     150
Irritable Urethra    .    .    .282
Lacteal Swelling      .     .     1^3
Lipoma of the Nose .    .    .108
Lupus, or Noli me langere  .     105
Malignant diseases of the Eye .  101
             "     "  Rectum  306
Medullary Cancer of the Testicle  222
Milk  Abscess    .    .    .     146
Nyctalopia    .'    .     .    .   93
Onjoc or Abscess of the Cornea    79
Opacities  and  specks  in  the
  Cornea    ....     81
Ophthalmia Tarsi, or Psoroph-
  thalmia   .     .     .    .     47
Paraphimosis  .    .     .     .289
Parulis, or Gum-boil   .    .     122
Preternatural   contraction    of
  Sphincter Ani    .     .     .   303
Files, or Hemorrhoids      .     294
  "   Inflammation and Strangu-
  lation of  .     .     .    .     298
Phimosis      .     .     .     .286
Polypi of  the Nose     .    .     108
Prolapsus Ani ....   300
    "     "  of the Iris    .     84
Psoas or Lumbar Abscess     .   167
Ptosis.....-53
Purulent Ophthalmia of Children   62
Ranula     .     .     .    .     120
Retention  of Urine        .     .   263
Salivary Fistula       .    .     Ill
Staphyloma   .     .     .     .82
Sclerotitis, Rheumatic Ophthalmia  70
Spina Bifida, Hydro Rachitis      176
Scirrhus  .....   226
Strictures  of Urethra   .    .     251
    "    " Rectum     .     .   304
    "    " Oesophagus   .     130
Scrofulous Conjunctivitis      .   65
    "     Testicle     .    .     221
Sympathetic Bubo        .     .   285
Trichiasis .       ...     83
Varicocele    ....   238
Wounds of the Brain      .     22
          "    Throat   .     .123
   "      "    Chest      .     136
   "      "    Belly    .     .151
Wounds of the Be^y, where the
  viscera  protrude hut are unin-
  juved     .    .     .     .     154
Wounds of the Belly, with in-
  jury and protrusion of the vis-
  cera    .    .    .             156
Wounds of the Belly, with injury
  of  the viscera, but no protru-
  sion    .....162
Wounds of the Belly, with ex-
  travasation   .    ".    .     .165
Wry  Neck, Caput Obstipum .     I3l


        SECTION  III.

             OPERATIONS

For Strangulated Femoral Hernia  202
  " Oblique Inguinal Hernia .    192 
CONTENTS.
XI
For Direct Inguinal Hernia  .     196
 " Trephining  .          .     401
 " Extirpation of the Eye    .   407
 " Removal of Superior Maxil-
  lary Bone     .     .    .     408
 " Bronchotomy    .     .    .419
 " Tracheotomy       .    .     422
 " Laryngotomy    .         .  422
 " Paracentesis Thoracis   .    425
 " Removal of a Diseased Breast 428
 " Paracentesis Abdominis .    431
 " Removal of a Diseased Testis 432
 " Amputation of the Penis .    438
 " Puncturing the Bladder    .  446
 « Lithotomy    .     .    .    450
 Amputation of the Thigh .    .  469
      «      at the Hip  Joint     483
      "      of the Leg   .    .  486
              "   Arm    .    488
      "        "   Fore-arm  .  490
Amputation at the Wrist          492
     "     of the Shoulder Joint  492
     "     of parts of the Hand  496
     "     of the  Fingers  .     497
     "     of parts of the Foot  502
Ligature of the Common Carotid
  Artery.....509
Ligature of the Arteria Innominata 512
     "    "  Subclavian Artery 514
     "    "  Brachial Artery    517
     "    "  External Iliac Ar-
  tery .....     519
Ligature of the Common Iliac
  Artery    ....     521
Ligature of the Internal Iliac Ar-
  tery .....522
Ligature of the Femoral Artery   522
     "    "    Popliteal Artery  524
Operation for Club Foot    .    525
Strabismus    ....  527 
                       ERRATA.

Page  284,  line  42,  ) Port au caustigUe} read} Porte au caustique.

      352,   "   2, bottom, long union, read, bony union.
      373,   "   31, top, brachiau, read, brachium.
      529, last line, Paucoast, read, Pancoast.
       "     "     Port, read, Post. 
THE
FIRST  LINES
OP THE
PRACTICE  OF  SURGERY.
                       SECTION II.

   Injuries and Diseases  of  particular  Organs and
                           Regions.

       INJURIES OF THE HEAD AND THEIR CONSEQUENCES.

   This  important subject will here be considered, as it relates,
   1st,  To superficial injuries; i. e. wounds  and contusions of the
scalp,
   2dly,  To fractures of the skull;
   3dly,  To icounds of the brain;
   4thly,  To compression of  this organ;
   5thly,  To concussion of it;
   6thly.  And to inflammation of the brain and its membranes from
external violence.

                    superficial injuries.

   In consequence of the free  intercourse,  subsisting between the
vessels of the pericranium and those of the dura mater, through the
medium of the  diploe  of the skull, inflammation on the outside of
the cranium is  apt to be propagated to  the dura mater.  This is
one reason why injuries of the scalp, especially contusions and  con-
tused  or lacerated wounds of it,  are generally more serious  than
similar injuries  merely  affecting the common integuments of other
parts  of the  body.  Indeed, it is  a maxim in  surgery, that no
wound of the head is so trivial as not to require the strictest attention.
   The scalp is often the seat of erysipelas, which, in  certain consti-
tutions, will be brought on by a very slight cut or contusion; the in-
   VOL. II.                    2 
14                 SUPERFICIAL INJURIES.
flammation spreading rapidly, and soon involving not only the scalp,
but the forehead, eyelids, and greater part of the face.  Too often
also, notwithstanding the most judicious treatment, delirium, or co-
ma, comes on, and  the  case has  a  fatal termination.  I  know  of
several instances, in  which the  removal of very small encysted tu-
mors from the head led to the production of phlegmonous  erysipe-
las, in  so  violent a form that the loss of life was the result.
   Contusions of the head frequently give rise to an effusion  of blood
under  the aponeurosis of the occipito-frontalis.   The swelling is
generally  soft in the centre, and hard at its circumference; hence
the feel of it may lead an inexperienced  surgeon to suspect, that the
accident is a fracture of the skull, with depression  of the bone.  In
other instances, the extravasated blood may lie immediately under
the scalp, and cover all the  upper part of the  head, raising up the
soft parts in  a manner that creates an alarming degree of disfigure-
ment.   In general, however, these  accumulations of blood under
the scalp, from blows  on the head, subside  very  favorably under
the use of a few brisk purgatives, and the application of lotions, con-
taining a proportion of the muriate  of ammonia, diluted acetic acid,
and camphorated  spirit.  If, however,  inflammation and  abscess
were not to admit of being prevented, fomentations, poultices, free
openings,  and  washing out all the  matter  and putrid blood with a
syringe and tepid water, would be the proper treatment.
   When the scalp is wounded, or severely contused, the hair should
always be cut off immediately; and, in many cases, it is a matter  of
prudence  to shave the whole scalp,  not merely that the wound  may
be rightly and  conveniently dressed, but that every part of the out-
side of the head may be seen and  duly  examined, and every mark
of external violence  detected.   Haemorrhage is,  of  course, to be
stopped, and the wound freed from extraneous substances, and clots
of blood; rules applicable to wounds in  general.
   Frequently the scalp is not merely wounded, but lacerated, bruised,
and more  or less extensively separated from the subjacent parts.   In
many instances, not only is the scalp thus torn and detached, but a
portion of the skull completely denuded, the aponeurosis of the oc-
cipito-frontalis muscle and the pericranium being  torn up  together
with the scalp.  Here the raised portion, or flap, of the scalp, how-
ever torn  and irregular it may be, should never be cut away, but  be
immediately replaced, and laid  down upon the exposed portion of
the cranium.   The scalp is exceedingly vascular, and nature is more
successful in repairing its injuries, than  circumstances would some-
times  lead us to anticipate.   At all events, the chance of its pre-
servation  and reunion should be taken; for, if we  succeed, we ma-
terially lessen the risk of necrosis of one or both tables of the skull.
Wethus  expedite the  patient's cure,  and obviate  the deformity
which would ensue,  either from  cutting  the flap away, or leaving it
more  or  less displaced from the  parts with which it was  naturally 
SUPERFICIAL INJURIES.
15
connected.   If slips of adhesive plaster and a bandage be not suffi-
cient to maintain such flap in the proper position, we ought to avail
ourselves of the assistance of the interrupted suture, making as few
stitches as possible, because they are  a source of irritation, and, in
this  situation, likely to promote the occurrence of erysipelas.   For
the same reason, when they  have been employed, they should be
cut and withdrawn  at an early period,  that is to say, on the removal
of the first  dressings.
   When erysipelas follows wounds of the head, it is to  be treated
according  to the rules delivered  in the first section of this  book.
Cold washes ought to be applied to the head,  copious venesection
practised, the free  use of leeches not  omitted, and the exhibition of
calomel, James's powder, and saline  aperient  medicines, actively
followed up in the early stages of the  case.   When abscesses seem
likely to form under the tendon of the occipito-frontalis muscle, and
to bring on sloughing  of that  aponeurosis, a free incision down to
the bone should be made  without delay.   It is an observation made
by Dupuytren, that, in phlegmonous erysipelas of the head, the in-
teguments  hardly ever mortify,  like  the skin of the leg from the
same disorder; and the reason which  he ascribes for the difference
is an anatomical fact; namely, that in the leg the integuments re-
ceive blood only by ramifications i^IH me iiDiai ana nouiar arteries,
which lie very deep, while the skin of the head has the occipital,
temporal, and  frontal  arteries  directly under it; consequently,  his
not so easily  destroyed by the mischief produced under the apon-
eurosis of the occipito-frontalis muscle,  as the skin of the leg is by
similar mischief between it and the fascia.
   In the treatment  of suppurating wounds of the scalp, one object
constantly requires our vigilance;  namely, that of preventing  the
matter from spreading widely  in the cellular tissue under the  scalp,
or in that under the tendon of the occipito-frontalis muscle.   We
must, therefore, be careful to  make  with promptitude the free open-
ings, which may be required  for this  purpose, and  to apply pres-
sure, with the view of preventing fresh accumulations.
   Frequently, when a portion of the scalp has been separated from
the subjacent parts, and replaced, it will unite at every  point;  but
in other instances, the union may not be general, and collections of
matter may form in certain  places.  Here one principal indication
is, to procure a ready  outlet for the  matter; for if we neglect to do
so, it will not only  destroy  whatever union may have taken  place,
but diffuse itself to a great extent, and  lead to a vast increase of mis-
chief and danger.  The loose cellular tissue, connecting the tendon
of the occipito-frontalis to the  pericranium, may also be the seat of
extensive abscess, and that aponeurosis itself mortify; though the
scalp itself  will not generally slough, for reasons already stated. 
16
INJURIES OF  THE  HEAD.
                  FRACTURES  OF THE SKULL.

   When the solution of continuity is very fine, it is termed a capil-
 lary fissure;  when more open, a. fracture.   The broken portion of
 bone may either continue  on a level  with the rest of the cranium,
 or be beaten in, or, as we say in the language of surgery, depressed.
 The inner table, being more brittle than the outer one, is  usually
 more extensively broken than the latter; and occasionally, violence,
 applied to the head,  will fracture the inner table, and actually cause
 a depression of it, though the outer table may not be at all broken.
   The most important distinctions are those of depressed and unde-
pressed fractures,  comminuted fractures, and fractures of the inner
 table alone.
   In young  subjects, depressions of the skull icithout fracture some-
 times happen; a circumstance owing to the softness and elasticity of
 the bones of the  cranium in the early periods of  life; and now and
 then cases present themselves, in  which the bones of the cranium
 are separated from one another at the sutures.
   When violence  is  applied to the skull, the fracture may not hap-
pen to  the part which is immediately struck, but in some other situ-
 ation more or less  remote from it:  this kind  of accident is termed a
 counter fracture, or,  more commonly, a counter fissure.  Fractures
 of the base  of the skull are sometimes  produced in this way, but
not always;  for a blow on the occiput or temporal bone may cause
a fracture extending  from the part actually  struck to the base of
the cranium.
  It was formerly  the custom to inquire of candidates for a surgical
 diploma the  symptoms  of a fracture of the skull; and I  have no
doubt that, in the times to which  allusion is now  made, certain  re-
plies of the  most erroneous kind were expected and given;  for ver-
tigo, paralysis, stupor,  loss of sense—circumstances specified by
writers and  lecturers, about thirty  years ago, as symptoms of  frac-
tured skull—really denote injury of the brain, or  disturbance of its
 functions, and not a fracture of the skull.   The  simple solution of
continuity in the bone, were it not accompanied by other mischief,
would  not be attended with any  particular circumstances denoting
its existence; and, in fact, every experienced surgeon knows,  that
many fractures of the skull are, on this account,  completely over-
looked—never discovered; and the patients get well without a single
bad symptom.  A mere crack in  one of the bones  of the cranium,
abstractly considered, is not more likely to produce any  serious com-
plaints, than a simple fissure in any other bone; and if  symptoms of
consequence do frequently attend  the accident,  they proceed either
from the bone being beaten inwards, so as to press  upon the brain,
or from the  mischief done to the parts within the  skull by the same
force that broke the bone itself.   The same violence which breaks 
FRACTURES OF THE SKULL.
17
the cranium, may occasion a concussion of the brain, an extravasa-
tion of the blood in or upon it, or subsequent  inflammation of  that
organ and its usual consequences.
   In Klein's Chirurgische  Bemerkungen (p. 161.), we find a re-
markable proof of the truth of these observations.  A man's skull
was so badly broken, that, after death, the left half of it could with
very little  trouble have  been  separated from the right; yet, after
the patient had  recovered from the first stunning, which lasted an
hour, he  remained  twenty-four  hours  without a single bad symp-
tom.
   A fracture without depression, then, is not, in  itself, productive
of any dangerous effects, or of any symptoms peculiar to it, or by
which  its existence  may be known.  Hence, if  the  scalp be  free
from wound, the accident is not likely to be detected at all; but the
want of precise information on this matter, I should say,  ought to be
of  no importance in practice, because the treatment should be  reg-
ulated  by  other considerations.   Thus, if  the symptoms  indicate
concussion or compression of the brain, or a tendency to inflamma-
tion of this organ, we are to act  accordingly, whether the bone be
broken or not.   We are led to adopt rigorous antiphlogistic treat-
ment, or to examine  the bone, with the view of  making a perfora-
tion of it, by entirely different reasons than  the existence of a sim-
ple undepressed fissure or fracture.   However, when the symptoms
indicate pressure on the brain, and the part  struck is  denoted by a
wound,  or  ecchymosis  of the scalp,  we are then called upon to
make an incision, for the purpose of ascertaining  whether any frac-
ture with depression exists; and, if this should not be the case, such
incision may still be useful, because, if the symptoms  call for the
trephine, the part that has been struck is generally the  proper  one
for its application, as being the most likely situation for any effusion
of blood, and for any splintering or depression of the inner  table.
However, when we trephine under these circumstances, in the  ex-
pectation of finding blood extravasated under the  part to which the
violence has been  directly applied, we sometimes learn that this is
not the case, and that  the pressure is neither  produced by an effu-
sion of blood on the dura  mater in this situation, nor  by any frac-
ture and depression  of the  internal table.    Experience  proves,
that blood is frequently effused in  or upon  the brain,  in situations
more or less remote from the part of the head which received  the
blow.
   We are  not  to suppose, then,  that fractures without depression
are not often accompanied by bad symptoms, but only that the mere
injury of the bone itself is not the cause of  them.  The same vio-
lence which breaks  the bone may cause a concussion of the brain,
an extravasation of  blood in or upon it, or a subsequent inflamma-
tion of it or its membranes.   But fractures with depression  are  a
very frequent cause indeed of dangerous symptoms, because neces-
                     2* 
18
INJURIES OF  THE HEAD.
 sarily attended with compression of the brain.   Yet, it is a curious
 fact, that the symptoms do not appear to be constantly in a ratio to
 the degree  and extent of the depression of the bone.   Sometimes
 fractures with a manifest and visible depression of the skull are not
 accompanied with any bad symptoms, or any of those effects known
 usually to arise from pressure on the brain.  I  was once called to a
 hackney coachman, a patient under the care of  Mr. Hooper, of the
 London Road, in one of whose parietal bones a depression as large
 as a crown-piece had been occasioned; yet he had no urgent symp-
 toms of pressure on the  brain, and  ultimately  got well without an
 operation.   We are not, therefore, to employ the trephine in every
 example of fracture with depression, but only in those cases which
 are made urgently dangerous by the existence  of  such pressure on
 the brain as this organ cannot quietly endure.   I believe it to be an
 excellent general rule in surgery, never to  trephine a patient for a
fracture of the skull, unless he be actually laboring under  coma,
paralysis,  and  other symptoms of compression in an  urgent  and
 dangerous degree,  excited  either directly by the pressure of the
 bone itself,  or by blood effused under it, or by suppuration under
 it, the  consequence of  a subsequent inflammation  of the dura  ma-
 ter.  One exception to the foregoing rule, sometimes specified, is a
 depressed fracture, occasioned by a pointed weapon, or a punctured
 fracture, as the injury is often termed; and the  reasons  assigned for
 such practice  are, first, that this kind of injury of the bone is al-
 ways attended  with a splintered state of the inner table;  and,  sec-
 ondly, that the patient will have the best chance of recovery, if the
 bone be removed before inflammation and suppuration of  the dura
 mater have had time to  take place.
   Fractures of the base oj the  skull are cases  of so perilous a na-
 ture, that they  are generally regarded as  inevitably fatal.   Wheth-
 er the opinion be true to  this extent,  is not an  easy point to deter-
 mine, because we  never know  positively, while the patient lives,
 whether the fracture has been  of this  kind or not;  and if he recov-
 er, we  have no opportunity of  ascertaining the point  by examina-
 tion.  Fractures of the base  of the skull  are  mostly  produced by
 the application of great violence to the lateral parts of the head, or
 to the vertex and base  through the spinal column.   If a person fall
 from a great height, and the top of the head come  to the ground,
 the skull is operated upon  by  two forces—the  resistance of the
 ground, and the pressure of the body upon the base of  the cranium:
 the bones are seldom displaced to any  extent; the dura  mater is
 generally lacerated; the substance of  the lower surface  of the brain
 itself wounded; and blood, consequently, effused at the base of the
 brain.   Indeed, such has been the degree of violence, that we  gen-
 erally find blood effused, not merely in this situation, but in others.
 I have opened  many persons who died with fractures of the base of
 the skull, and the mischief noticed within their  heads corresponded
 in every respect to what has now been described. 
FRACTURES OF THE SKULL.
19
  Bleeding from the nose, mouth, or ears, when attended with oth-
er circumstances, evincing the  receipt of a violent injury of the
head, and much consequent  disturbance of the  functions of the
brain, has been frequently insisted upon as denoting a fracture of the
base of the skull.   Sir  Benjamin  Brodie relates  one example of
such a fracture, which was attended with  haemorrhage from the ear,
and where the source of the blood was found, after death, to be the
lacerated  carvernous sinus.  Perhaps, however, no great degree of
importance  can generally be attached  to this symptom; for such
bleeding sometimes comes on from slight injuries, not at all affecting
the cranium or its contents; while other cases are  met with, where,
on dissection, extensive fractures are found of the  petrous  portion
of the temporal  bone,  and of  the sphenoid and ethmoid  bones,
though no bleeding at  all had  occurred  from the ears,  nose,  or
mouth.
   Treatment of Fractures of the Skull.—If the  fracture be unat-
tended with depression, or  with  symptoms  of a  dangerous degree
of pressure, either from this cause, or from extravasation of blood,
we must  direct our  views  to  the prevention of another source of
peril, namely, inflammation of  the brain,  which may, perhaps,
sometimes, be caused  by the mechanical  irritation of the inequali-
ties of the fracture,  but generally by the same violence which broke
the bone  itself.   When the broken  bone  is  not depressed, we can
scarcely venture  to trephine on the supposition  that  the  inflamma-
tion of the dura mater and  brain, which  often follows such an  in-
jury, is owing  to the  mechanical irritation  of the irregularities of
the fracture; and, if this should not be  the cause  of the  inflamma-
tion, as T believe it seldom  is, then the infliction  of additional me-
chanical injury by the operation would be the least rational and ad-
visable measure that could possibly be adopted.   Here,  it appears
to me far more prudent to be content with antiphlogistic treatment,
such as cold washes to the head,  venesection, arteriotomy, leeches,
the free exhibition of calomel,  with tartarised antimony, saline pur-
gative  medicine, and  barley  water or  tea  for  sustenance.  Nor
should the antiphlogistic regimen be altogether discontinued till three
or four weeks have elapsed; for the records  of surgery prove, that
a disposition to inflammation of the  brain  and its membranes lasts a
considerable time after  the  application of external  violence to the
head; and such  disorder has  attacked and  proved  fatal to many
who, supposing all risk over,  have returned,  prematurely, to  their
usual mode of living.
   Some very interesting cases, illustrating this  fact, are contained
in Pott's works,  and  Klein's Chirurgische  Bemerkungen  (12mo,
Stutgard, 1801,  p.  113.,  &c.)   In some of these examples, the
patients remained well and sensible more  than a month after the re-
ceipt of a blow on the head, and  were then seized with fever, shiv-
ering,  convulsions,  paralysis,  &c, -which  soon  destroyed them.
What is particularly  worthy of notice is, that, in some of the cases, 
20
INJURIES OF  THE HEAD.
though the symptoms began thus late, and  perhaps proved fatal  in
two or three days, a large  portion of the  brain and  its membranes
were inundated with matter; parts of it destroyed; its  membranes
considerably thickened, and even broken.   We must here suppose,
either that such disease was going on for a time, without producing
any particular bad symptoms, or that its  progress was most rapid
after it had once begun.
  [Many practising surgeons have had the opportunity of seeing ca-
ses of concussion  terminate fatally, some weeks  after the accident,
when the patients  have  supposed themselves well, and  have  returned
to their occupations.   A susceptibility to inflammation of the brain
and its membranes, continues for  a long time, from one to six months.
The following case illustrates what I mean.   W. B., farmer,  aged 24,
of good constitution and habits, while engaged  in stoning a well, was
struck upon the back part of the head,  by  a stone weighing five or
six pounds.  He was knocked down, and all the usual  symptoms of
concussion supervened.   Under the ordinary antiphlogistic treatment,
he recovered in two weeks.  He  seemed entirely well when we dis-
charged him, and  all the functions were acting in harmony.  He was
apprised  of the danger to  which he would  expose  himself, if he
should  return to his ordinary out door labors.
  He fdt well, and  hence concluded the  cautions of  the  surgeon
a matter of supererogation.  It was December,—there had been a fall
of snow, and  his sheep were still  out.  He  therefore,  regardless of
all advice to the contrary, went out in pursuit of his flock.   The night
following, he was attacked  with a chill, inflammation  of the brain
ensued, and in ten days from the time, he  died, despite all the aid
that could be afforded.   This patient would  certainly have recovered
if he had followed the cautious course which had  been laid down for
him.—Ed.]
  A doctrine has arisen,  that  fractures of the cranium,  attended
with a  wound of the scalp directly over  the injury of the bone, are
accompanied by  much greate danger  than  other fractures of the
skull,  uncombined with such a wound.   In short, it is  alleged, that
there is the same  difference in this respect as prevails between sim-
ple and compound fractures of the bones of the extremities.   This
is the belief entertained by that highly respected  surgeon Sir  Ast-
ley Cooper, whose views of every part  of surgery have great ex-
perience for their foundation.  The point is important, because the
doctrine might deter  us from examining the state of the skull by an
incision, and applying the trephine, when  the patient's safety,  per-
haps,  depended very essentially  upon such measures not being post-
poned.   Surgeons, who subscribe to this view of the  subject, will
naturally  be as much  afraid of  cutting  down to a fracture of the
cranium when there is no wound, as of cutting  into a  simple  frac-
ture of the leg, and  making it compound.   They will  be inclined
to avoid this proceeding, and, of course, to refrain from trephining,
whenever the fracture is  not accompanied  by a wound; while, if
the fracture happen to be already exposed by  the accident, they
would  probably apply  the trephine for precisely the same symptoms 
FRACTURES OF THE SKULL.
21
as they conceive would not justify it when no wound  of the scalp
exists.  If I feel certain of any thing  in surgery,  it is that the de-
cision for the operation of trephining should depend upon the symp-
toms of pressure on the brain being urgent, dangerous, and unequi-
vocally manifested; and,  I believe, whether  there  be a wound of
the scalp or not conjoined with a fracture of the skull, it is our du-
ty, under those circumstances, always  to examine the state of the
bone, and not to let our conduct be at all influenced  by any anal-
ogy, whether true  or not,  between these cases and simple and com-
pound fractures of the limbs.   If the  doctrine be true,  however,
which I am by no  means prepared to deny, it  should certainly teach
us not to use the knife without any real occasion  for an  inspection
of  the bone.
   In the time of the  French Academy of Surgery, it was custom-
ary to employ the  trephine, or rather the trepan, in almost all cases of
fractured  skull, not merely for the removal of any urgent symptoms
present, but with the view of preventing their occurrence at all.  The
absurdity of the latter doctrine received a complete exposure from
the facts and observations published by the late  Mr.  Abernethy,
whose investigations  into  this difficult  part of surgery  contributed
very essentially, as I think, to its improvement, more especially by
showing in what cases the application of the trephine might do good,
and in what instances the operation  should not be undertaken.
Even at  the present  day,  his advice is sometimes neglected; for  I
am continually hearing of persons being trephined  under circum-
stances in which,  according to the  principles  established by his  re-
searches, they cannot possibly be benefited by the removal of any
part of the cranium.   Here,  so far as  I  can judge,  the nature of
the symptoms actually existing should  be the guide;  and, instead of
admitting the wisdom of the old  rule  of trephining, in anticipation
of  bad symptoms  which are only apprehended, but  may never oc-
cur, I should say  that the plan is altogether contrary to the dictates
of  reason and  experience.   As  Mr.  Abernethy observed,  if the
brain will, in the  first instance, bear  a  certain  degree of pressure
without ill  consequences,  whether from fracture or effusion,—if it
will, at first, bear  it without production of urgent  symptoms, or ir-
ritation of the  dura mater  by the  inequality of a  fracture,—why
should it not continue to  do so subsequently?  Dupuytren records
the case  of a banker at Paris, who was lately living in perfect health
with a considerable depression of the cranium, though the accident
took place many years ago.  Yet Velpeau's observation on this and
other similar facts  is,  that, for one patient who gets well under such
treatment, ten would  die.    It is also not to be denied that, in  some
instances, the leaving of the bone depressed has been followed, at  a
subsequent period  of  life,  by severe, and even fatal, affections of the
brain and nervous  system.   It may be asked, then, why do I not
approve  of  trephining every  fracture  with depression, whether at- 
22
INJURIES OF THE HEAD.
tended at first with urgent symptoms or not?   My answer is, that I
cannot recommend this plan, partly for the reasons stated by Aber-
nethy, and partly because I doubt whether the cases of subsequent
inconveniences, or dangers, from the continuance of the bone below
its proper level,  when the depression caused no  bad  symptoms  at
first, are numerous and common enough to be a foundation  for what
ought to be the general plan.  Supposing the scalp were wounded,
the fracture of the skull comminuted, we ought to extract all the
loose fragments; for they are already  detached, and might cause
irritation of the dura mater.   This practice would  be conformable
to the general rules relative to  the treatment of all wounds, wher-
ever situated.  But, if  the pieces of bone were not completely de-
tached, so that  they could  not  be removed without an operation,
and no bad symptoms existed,  I  should  be  inclined  to  join those
surgeons, who do not recommend an operation  under these circum-
stances.
  One consideration which  influences me in defending the princi-
ple, that the  trephine  should not be  used in injuries of the head,
unless bad symptoms  actually  exist, and are of that description
which may be relieved  by this measure, is, that the operation itself,
viz., the removal of a portion of the skull, and the exposure of the
dura mater, are  proceedings attended with some considerable  risk
of bringing on bad, and even fatal, consequences.   The late Mr.
Ramsden was rather fond of operating; and I remember very well
two cases, in which he  tried what the trephine would do for the re-
lief of a long-continued fixed pain at one part  of the  head.   A
piece of bone was sawn out in each case; inflammation  of the du-
ra mater ensued; and,  in two or three days, each patient fell a vic-
tim to the experiment.   The removal of  a portion of the  cranium
is also followed,  in a certain number of examples, by a gradual pro-
trusion of the brain through the aperture—a hernia  cerebri, which
generally has a fatal termination.
                   WOUNDS  OF THE BRAIN.

  Many fractures with depression produce a laceration of the mem-
branes, and even of the substance, of the brain.  This organ,  im-
portant as are its functions,  is frequently wounded without the event
being immediately productive of those  perilous symptoms which
might be expected,  but there -is a difference  in  this  respect,  the
reason of which is not at  present satisfactorily understood:  in some
cases, a comparatively slight wound of the brain gives rise to se-
vere and rapidly fatal consequences; while, in others, the same de-
gree of  injury, so far as it can be ascertained,  occasions no  serious
symptoms.  In the Memoirs of the  French  Academy of  Surgery
are detailed  various recoveries from most serious  injuries of the 
WOUNDS OF THE BRAIN.
23
brain;  such cases as would a  priori have been regarded as com-
pletely hopeless.   If we look over the annals of surgery, we find
numerous cases in which the patients were  cured, notwithstanding
the brain had  not  merely  been wounded, but portions  of it torn
away, or separated.   In one  of the  volumes of the Medical and
Chirurgical  Transactions of London are the  particulars  of a boy,
through whose frontal bone the linch-pin of a gun  was driven with
such violence that it lodged in the anterior lobe of the brain.  Di-
rectly after  the injury, he walked several hundred  yards, and then
fell down, and was seized  with convulsions.  No suspicion was at
first entertained of the  passage of a foreign  body into the  brain.
Venesection and other antiphlogistic measures were put in practice;
and, on the following day, the urgent symptoms had  abated.  The
boy was treated on this system until the 27th day,  when a  piece of
iron was noticed at the bottom of the  wound, and  extracted.   It
proved to be the  linch-pin of a fowling-piece, a substance of con-
siderable size and  weight.   A cure  ensued, with  the  exception of
an amaurosis of one  eye.   A  French  soldier was wounded at  the
battle of Waterloo:  a musket-ball entered  at the anterior portion
of the squamous suture, lodged in the substance of the brain; and
on the fifth day, after an enlargement of the wound, and the remo-
val of several fragments of bone, it was extracted from the poste-
rior lobe of the right hemisphere of the brain, where it had rested
upon the  tentorium.   Headache and  partial  deafness of the right
ear were the only  bad  symptoms.   A  recovery took place.   How-
ever, I believe the history of this  part of surgery  will warrant  me
in representing wounds of the  brain as generally attended with vast
danger; and that,  even if no bad symptoms occur directly after the
accident, they mostly come on and prove fatal afterwards.   Paro-
isse gives an account of twenty-two French soldiers, [from whose
skulls portions of bone, with the scalp and slices of  the upper part
of the brain, had been separated by sabre wounds.   All  these men
ultimately died; but at first they had  no bad symptoms,  and actu-
ally performed a journey of ninety miles after the receipt of their
wounds, one half of which distance they travelled on foot.
   Surgeons may be called upon  to perforate  the  cranium for  the
removal of balls lodged within  its cavity.   Larrey relates some ex-
traordinary examples of this practice;  and it  was  he who first sug-
gested the necessity of sometimes making a counter-opening in  the
bone for the  accomplishment of this purpose, when the ball had
passed to some point of the surface  of the  brain  remote from  the
opening by which it  had entered.   He  introduces  an elastic gum
catheter along the track of the ball, and makes a perforation with a
trephine over the part where he feels that it is lodged.   Now, one
of these histories is very curious; for, after having removed a por-
tion of the skull with the trepan, he  took  out  an iron  ball, that
weighed seven French ounces, which was lodged upon the anterior 
24
INJURIES OF  THE HEAD.
lobe of the  right hemisphere  and  against the orbitar process and
spine of the  os frontis.   The patient  suffered a painful  sense  of
weight in his  head; and  whenever  he inclined it [backward he was
seized with syncope.  Here, also, the  case ended in the recovery
of the patient.
   In the treatment of injuries of the head, attended with a wound
of the dura  mater or substance of the  brain itself, if no particular
symptoms or circumstances  immediately demand the trephine, our
chief reliance should be upon rigorous antiphlogistic treatment; the
same plan as  already advised for fractures unattended with urgent
symptoms of compression.   The  external wound  itself is  to be
treated  on common  principles;  it ^is  to be made  clean; foreign
bodies, or fragments of bone, are to  be taken out, and its  sides
brought together.   Such cases  commonly  end  fatally; but we
must not absolutely despair of them, for the injury, and even a con-
siderable loss of substance in the  upper part  of the himispheres,
may occur, as we find in the cases  which  I have quoted, without
being necessarily fatal, or even productive of very alarming symp-
toms.
   Wounds of the dura  mater and brain are sometimes followed by
hernia cerebri, which then often appears to  have  a considerable
share in occasioning the patient's  death.
   [We are to bear in mind, that when the brain  is injured, the dan-
ger is always  in proportion to the concussion, and not to the amount
of laceration.
   In several cases, we have removed portions of brain, and the patients
have  recovered without  any untoward  symptoms.  Such  cases are
produced, when the violence  applied strikes obliquely, and as it were
brushes the head,  instead of  coming upon it perpendicularly.—Ed.]
                COMPRESSION  OF THE  BRAIN

May  arise  from  fracture  with  depression,  from an  extravasa-
tion of blood within  the cranium, or from a collection of matter in
the substance of the brain, or between  the inner table and the dura
mater, in  consequence of previous  inflammation, the  symptoms of
which must than  precede  those which usnally accompany the in-
jurious effect on the brain.   Compression of the brain may also be
produced  by the lodgment of balls  within the cranium,  or by the
formation  and  growth of tumors.  When such pressure exists,  it
cannot  be expected  that the symptoms  will  be  alike in all cases,
because the pressure not only differs in respect to its cause, its de-
gree, and  its situation, but it differs also in another important point
of view, namely, [that  relating to the kind and quantity of other in-
jury, or mischief, with which such pressure may be conjoined.   For
we find in practice, that every case of  pressure, following external 
COMPRESSION  OF THE BRAIN.
25
violence, is not so clear as many writers would lead  us to suppose;
and that we do not always have  mere pressure to deal with, but of-
ten pressure combined with iconcussion, with inflammation, or with
a wound or laceration  of the membranes or substance of the brain.
In short, we frequently have to exercise our judgment on what may
be called mixed,  or complicated, cases,  in which the symptoms do
not correspond altogether to those either of compression, concus-
sion,  or inflammation singly.   Yet,  if we  understand the  general
character of the symptoms resulting  from each of these states, we
shall  be in a great measure qualified to judge of the effects likely to
be the result of their  happening to be coexistent.
   It may be thought that apoplexy will give us the best illustration
of the symptoms  of simple compression of the  brain;  yet this is
perhaps not precisely the case, because apoplexy is  often preceded
by disease of the brain; and, at all events, as good an illustration of
them is afforded by certain cases, in which, after the receipt of a
blow on the head, the patients recover from their stunned state, im-
mediately following the blow, and shortly afterwards begin to labor
under the effects  of an effusion of blood, gradually going on within
the head.
   The symptoms of compression of the  brain are headache, stupor,
and drowsiness; and, while the  quantity of effused  blood  is small,
they may be the chief symptoms.   Afterwards, when it increases,
and the pressure  on the brain is greater, there will be a  loss of all
sensibility, and of all power over the voluntary muscles.   The eyes
will remain half open, the retina will be perfectly insensible, the pu-
pils will  generally be  dilated, and  the iris quite motionless,  even
when a candle  is   brought close to  the eye.   The patient may be
pinched or pricked, but he is perfectly unconscious of it: the blad-
der, being paralytic, cannot empty  itself; or its  sphincter and  that
of the anus being in this state, the urine and faeces  come away in-
voluntarily.  The pulse is slow, and respiration carried on with dif-
ficulty and a stertorous noise.
   The observations,  already delivered respecting mixed or compli-
cated cases, enable us at once to perceive  that, even when com-
pression of the brain exists, and this  in an unequivocal manner, the
symptoms may be modified by the particular complications attending
it.   Thus, frequently, one pupil may be contracted, and  the other
be dilated; or the patient may be paralytic on one side, and convuls-
ed on the other.   My  experience teaches me,  that convulsive
twitches of the muscles are rather a  symptom of laceration of  the
brain, than of simple compression.   They often attend fractures
with  depression.
   In compression,  there is usually  no sickness and no vomiting.
This fact is well exemplified by cases, in which  the patient is free
from these symptoms until he has been trephined, and then the re-
moval of  the pressure is sometimes immediately followed by the re-
jection of  the contents of the stomach.
   VOL. II.                   3 
26
INJURIES  OF THE  HEAD.
   Another fact which deserves notice is, that, when pressure exists
 only on one side of the head, the paralysis generally manifests itself
 in parts on the opposite side of the body.  Complete  hemiplegia,
 however, is much more rarely the consequence of  accidental  inju-
 ries of the head, than of apoplexy; a difference,  perhaps, referable
 in  these cases to the difference in the situation   of  the  effused
 blood.
   With  respect to paralysis, though  it is a common  symptom of
 pressure, various facts prove, that it may also arise from concussion.
   Too much attention  cannot  be paid to  one circumstance, fre-
 quently throwing considerable light on these cases.   I allude to  the
 patient sometimes recovering his senses, after having been stunned
 by the blow, and then relapsing into a drowsy condition, which is
 soon followed  by all  those symptoms already specified  as denoting
 compression of the brain.   That these symptoms cannot  depend
 upon  concussion is manifest;  for then the patient would not have re-
 gained his senses for a time, a fact proving that the stunned condition
 of the patient, or the immediate  effect of the concussion, had sub-
 sided.  That the symptoms cannot depend upon  a  depressed frac-
 ture is equally manifest, because the patient would have been sense-
 less from the first, and  have  continued so  without remission.    That
 the same symptoms cannot  depend  upon the  lodgment of matter
 beneath the skull is certain, because there  has not been time  enough
for inflammation and suppuration to occur.   The real cause of the
 return of the  loss  of sense, then,  under these circumstances,  be-
 comes tolerably evident, and is  accounted for  by the extravasation
 continuing slowly to increase, and to produce more and more  pres-
 sure,  and its usual consequences, notwithstanding it had not advan-
 ced sufficiently at first to prevent the return of  the mental faculties,
 on the subsidence of the immediate effects of the concussion which
 the brain had sustained.
   When no interval of  sense takes place, but the patient lies insen-
 sible  and motionless from the first, then we can only form  a judg-
 ment of  the cause of this  state of the system by  the consideration
 of other  symptoms.  Frequently cases of this  kind are particularly
 unfavorable, as being complicated ones, combining  concussion and
 compression together;  and not only these evils, but  a wound or la-
 ceration  of the brain, and even a fracture at the base of the skull
 or elsewhere.
   Extravasations of blood between the dura mater and the  base of
 the cranium are mostly  fatal.   When the blood lies between  the
 dura  mater and the tunica arachnoides,  it is often widely diffused,
 so as not to admit of being effectually  discharged.   When situated
 on one of the hemispheres, between the cranium and the dura  ma-
 ter, however,  it is often circumscribed, and may be discharged by a
 perforation of the bone.
   There is  frequently extreme difficulty in forming an opinion about 
COMPRESSION  OF THE BRAIN.
27
the precise situation of extravasated blood, even  when  symptoms
indicate such extravasation.  Generally we know not whether the
blood lies on the dura mater or in a deeper situation, or under what
part of the cranium.  Now, if the symptoms be urgent, the rule is,
that we are to be guided in the choice of a place for the application
of the trephine by any mark of violence on the scalp, or any wound
or fracture showing the part on which the violence has acted;  for it
is  directly under it  that the extravasation is frequently, though not
constantly, situated.  We should also consider on which side of the
body  the paralytic effects show themselves, as the probability is,
that the pressure is on the  hemisphere of the brain of the  opposite
side.   But, supposing there were twitches, or spasmodic action, of
the muscles of the arm  or leg  of the opposite side, with  paralysis
of the limbs on the same side, as the mark of violence, the surgeon
should not  trephine in the expectation  of the  blood  being effused
under that part of the skull which received the blow.  In  Univer-
sity College Hospital,  I have had several cases, confirming the cor-
rectness  of  this advice.
   Sometimes there is no mark of external  violence on the  head, no
wound to guide  us, no restriction  of paralysis to one side of the
body, no interval of sense.  Here circumstances are desperate, and
we have no choice, but either that of trusting  to  means calculated
to stop the  further effusion of blood  in the head, viz., cold washes
and venesection,  or that  of perforating the cranium without any
kind of clue to the situation of the effused blood.
   Under these circumstances,  the generality of practitioners would
be content with bleeding and antiphlogistic treatment; while others,
knowing that when a considerable  quantity  of blood is  effused on
the surface  of the dura mater, it is generally poured  out  from the
middle meningeal artery, might feel disposed to trephine in the track
of that vessel.   Were there any guide  to the  side of the  head on
which the extravasation lay, this bold measure might be warranted;
but many surgeons would rather confide in antiphlogistic treatment,
and it is  not for me to pronounce  such decision erroneous.  Often
the blood is on both sides, or at the base of the skull likewise; and
sometimes not only so, but not under the part struck.
   When dangerous compression of the brain arises from a fracture
with depression, the indication is to elevate  or remove  the portion of
bone forced below the level  of the  rest of the  cranium.   For this
purpose, we are to adopt  certain modes of proceeding,  which will
be explained when I describe the operation of trephining.
   Also when suppuration occurs on  the surface of the dura mater,
and produces urgent symptoms  of pressure,  the same operation is
indispensable ; but this case is generally not one of simple compres-
sion,—it has been preceded, and  is usually  still accompanied, by
inflammation under the cranium, affecting not merely the dura mater,
perhaps, but the brain itself.   In the museum of University College 
28
INJURIES OF  THE  HEAD.
 is a cranium in which a  small exfoliation has commenced, in conse-
 quence of suppuration on  the dura mater.   It is  one  of Pott's
 cases, as they are called, in consequence of his having particularly
 described  them.   In this instance,  the trephine was applied,  and
 the dura mater found red and spongy.   But the case was not one of
 simple pressure;  for besides the disease of the dura mater, another
 preparation, taken from the  same patient,  exhibits a deeply-seated
 abscess in the brain, about an inch below  that part of the skull
 which is undergoing  exfoliation.
   The  patient, before exhibiting the symptoms of pressure, must
 have had those of meningeal inflammation,—he must have had se-
 vere pains in the head, shiverings, an accelerated pulse, and disturb-
 ance of the intellects,  followed by coma, and  loss of  sense, and
 generally a puffy circumscribed tumor of the scalp, and detachment
 of the pericranium, corresponding to the extent of the abscess be-
 tween the inner table and the dura mater.   Or, if there were an  ex-
 ternal wound, its lips would have lost their vermillion color, become
pale, flabby, and  swollen, and the discharge changed  to a  scanty
foetid ichor.
   Such a case calls  for the  immediate perforation of the bone, and
rigorous antiphlogistic  treatment, copious bleedings,  leeches,  the
repeated exhibition  of calomel and James's  powder,  and saline
purgatives, with abstinence and quietude.
CONCUSSION  OF THE  BRAIN
Has many  degrees, as may  readily be conceived, when  the great
difference which exists  between its two extremes is recollected,__
the slight transient stunned condition of the patient, the sudden ef-
fect of a moderate blow on the head, and that complete disorgani-
sation which, at the moment of the injury,  permanently annihilates
all the powers of  life.
  When the concussion is slight, the patient may be  stunned only
for  a  few seconds, or minutes,  and a degree of headache, followed
by acceleration of the pulse, vertigo, and sickness, may take place;
but, m general, none  of these effects continue long if depletion be
employed.  However,  in some examples,  a  very slight blow on
the head will bring on inflammation of the dura mater, and this some-
times long after the accident, when all apprehension of danger has
ceased.                                                 b
_  When the violence applied to the head is greater,  the  patient is
immediately stunned :  his extremities  become cold ; his  >,lse is
feeble, slow, and intermitting; his respiration difficult,  but  eenerallv
without stertor; and his sensibility and power of motion are entirelv
abolished.                                                    J
  This is tbe^nrf stage of concussion,  or the first effects produced 
CONCUSSION OF  THE  BRAIN.
29
by severe degrees of it.   Such a state cannot last long, lor the pa-
tient either dies in a very short time, or the effects which I have been
describing gradually subside,  and are succeeded by others,  which
may be said to constitute the second stage of concussion.
  In this the  pulse and respiration improve, and, though not  regu-
larly performed, are sufficient to maintain life, and to diffuse warmth
over the extreme parts of the body.   The nervous influence  is also
now so far revived, that if the skin be pinched the patient is con-
scious of the  injury; and in many cases the contents of his stomach
are  thrown up;  but he  lies in  a dull stupid state, quite inatten-
tive to slight external impressions.  In proportion as the first  effects
of the concussion subside a little more, he becomes  capable  of re-
plying to questions put to him in  a loud tone of voice.   So long,
however,'as the  stupor remains, the inflammation pf the brain is mod-
erate; but as the former abates, the latter seldom  fails to increase,
so  as to bring on the third or inflammatory stage of concussion.
   In this third stage, if the eyelids be opened, the patient will shut
them again  in a peevish manner;  the  pupils are contracted,  and a
strong light is very offensive.   The patient is sleepless;  talks much
and incoherently; and,  if not restrained, will get out of bed, and
act with frantic  absurdity.   As the delirium increases the pulse be-
comes small,  very quick, and even rapid; and, if  the  inflammation
of the brain be  not checked, suppuration, or effusion,  will  occur
within  the head, preceded  by rigors, and the foregoing symptoms
change into others, arising from  the pressure  of the fluid on the
brain.
    The dangers, then, of concussion  depend upon its original  vio->
lence, which  may be such as to kill the patient at once, or upon the
inflammation of the brain and  its consequences often following the
injury.
   With respect  to the sickness  and vomiting,  they are generally
early symptoms, and seldom continue after the patient has recover-
ed from the first shock of the accident.
   Concussion and compression, we know, are often combined; and
this fact will  explain why  the symptoms frequently have not the
simplicity we might expect from some descriptions given of  them.
    Patients, who recover from severe degrees of concussion, some-
 times  remain variously and curiously affected by the the accident
 during the  remainder of their lives.   Imbecility,  loss of memory,
 and a marked change in the character are sometimes the permanent
 consequences.   The patient may have loss  of hearing, or  partial
 paralysis.  In consequence of an accidental concussion of the brain,
 a patient, previously a lunatic, has been known to recover his reason.
 In other instances, the patient, at first, can only remember circum-
 stances with which the mind had been lately impressed, but after-
 wards recollects nothing but what happened in his chidhood.   £ orae-
 times one effect is the total forgetfulness of  a language, with which
                             3* 
so
INJURIES OF  THE  HEAD.
 the patient was previously familiar.   Mr. Liston attended a woman,
 who recovered her hearing entirely from the accidental effects of a
 concussion  of the brain.   I lately attended a lady in  the Regent's
 Park, who met with a concussion of the brain from her horses tak-
 ing fright and galloping away with the carriage till it came  in con-
 tact with some iron railings: in this example, the patient has not the
 slightest recollection of having met with any accident  in the Park;
 nor does she remember the circumstance  of the  horses galloping
 away with her, or the fall of her ccachman from the box.   During
 my attendance on her, with the late Dr. Pinckard, she never advert-
 ed to the injury of her head, but repeatedly to a slight burn of her
 neck, which she  had met with two or  three  days  before  the other
 more serious injury.
  I believe  there is great practical utility in  dividing  concussion of
 the  brain into the three stages which I have described, because the
 treatment should  be regulated accordingly.   In the first stage, the
 taking away  of blood must be improper and  dangerous, the powers
 of life being already reduced to the lowest ebb; and, consequently,
 an attempt to reduce them further would be  contrary to the dictates
 both of reason and experience.   The  patient, in fact,  is already
 in danger of dying, without any reaction taking place in the system,
 and nothing  would be more likely than  bleeding to render  the risk
 of this termination still greater.  On the contrary, the indication is
 to endeavor to rally the depressed state of  the  system, for which
 purpose  warmth should be applied to the surface of the body, and
 especially to the epigastrium and extremities, and  stimulants to the
 nostrils.   These I consider safer means than the  internal adminis-
 tration of cordials and spirituous medicines, which,  after the revi
 val  of the patient, always begin to have the most pernicious effects:
 However, some practitioners venture  to give ammonia  or ardent
 spirits by the mouth,  or even to  throw  up  turpentine clysters.
 From these  plans  I  should  always abstain myself, and be content
 with external stimulants, which can be  discontinued directly if thev
 are no longer needed, without any hurtful prolongation of their ac-
 tion.
  In the second stage,  in which the freedom of the circulation has
 been restored, and a disposition to inflammation of the brain com-
 mences,  all  sources of excitement should be removed.   The pa-
 tient should  be kept perfectly quiet  in a  darkish  room,  the  head
 should be shaved and covered with cold applications, blood be ta-
 ken away, the bowels freely opened with calomel and  antimonial
 p wder, and the functions of the bowels and  skin promoted with
 saline aperient draughts.   When the circulation rises a little more
 the pulse quickens, and the fever and cerebral excitement have ta-
 ken place, the lancet, assisted with leeches,  small repeated  doses
 of tartarised  antimony, and cold washes to  the head,  may be said
to be the sheet-anchor.  At this period, we should  bleed fearlessly 
CONCUSSION
OF  THE  BRAIN.
31
as often as the pulse rises above a certain  point; for if we  do not
check the  disturbance of the circulation,  the inflammation  in  the
head will certainly  increase, and the patient  die.   It is in cases of
this description that arteriotomy is frequently practised.
   The third stage is that of complete phrenitis, requiring quietude,
bleeding, purgatives, calomel, tartarised antimony, and cold evapor-
ating lotions on the head, and, after a time, blisters on the scalp, or
the application of the antimonial ointment to it.   When  bleeding
can no  longer be  continued, and there is  risk of effusion upon the
brain, we should give calomel freely, or employ mercurial frictions,
so as to excite a salivation.
   When  all risk of arterial excitement is  over, and certain  imper-
fections and  infirmities of the intellectual and muscular systems re-
main, seemingly as consequences of effusion, or some other perma-
nent changes in the brain,  the patient should be put under  the influ-
ence of mercury,  and  the  scalp blistered,  or rubbed with  the oint-
ment of the  iodide of potassium.
            HERNIA  CEREBRI, ©R ENCEPHALOCELE.

   As a subject intimately connected with the consideration of injuries
of the skull, I will now make a few observations on hernia cerebri,
or encephalocele, as it is sometimes called, which signifies a gradual
protrusion of a portion of the brain through a preternatural opening
formed in the skull, either by the  trephine, or by the exfoliation of
a portion of bone in the state of necrosis.   In children, indeed, the
protrusion has been  known  to  happen  through an  opening in the*
skull, left by its incomplete ossification.   When hernia cerebri fol-
lows the application of the trephine, or the loss or removal of bone
from other causes, some days generally elapse before the brain be-
gins to  protrude through the aperture; and this occurrence is pre-
ceded by ulceration, or sloughing, of the dura mater, without which
circumstance probably there would be no protrusion at all in ordi-
nary cases; I mean such as follows the removal of bone by the tre-
phine.   The tumor soon attains the size of  a pigeon's egg, and its
circumference is pressed upon by the edges of the opening.  There
is great tendency to haemorrhage from the surface of the protruded
mass, and consequently the  tumor is  usually covered with layers of
coagulated blood.   In some few cases, the patients do not lose their
senses; though in  by far  the greater number of examples  they lie
in a comatose state; and if coma does not exhibit  itself at  first, it
always comes on in the advanced stage of the disease.   The imme-
diate cause of hernia  cerebri is obscure and unsettled, no com-
pletely satisfactory explanation of it having  yet been given by any
pathologist.  It is said to  arise in consequence  of the removal
of bone;  but this is not the only cause, for if it were so, the  pro- 
32
INJURIES
OF  THE  HEAD.
   trusion would always follow such loss of bone, which is contradict-
   ed by experience.   The ulceration of the  dura mater, and  other
   changes, appear  to  be concerned.   The cortical  and medullary
   portions arc often distinctly visible in the  protruded mass, and  the
   pia mater is seen dipping down into  the sulci,  and  enveloping  the
   convolutions.   Occasionally  the  tumor ceases  to enlarge,  ac-
   quires a brownish color, pours out a foetid matter, and  breaks into
   several pieces, which afterwards separate, and are thrown  off; and
   then  granulations  will sometimes  arise,  and the  patient  recover.
   This  favorable termination,  however, is rare; aud I have  seen
   so few patients get well who had  hernia  cerebri, that the progno-
   sis seems to me very unfavorable, more especially when our  igno-
  rance  of its proximate cause is taken into the account.   In France
  it used to be the practice to dress the swelling with a  pledget dipped
  in wine.  Such an application, one would suppose, could not  pro-
  mise to be very serviceable; yet Larrey and  others  prefer it.   In
  this country, pressure in moderation has sometimes been tried, and
  even the bolder method of slicing off the protruded part of  the cer-
  ebral  mass.   As  a linen compress cannot  be so exactly applied
  as a plate of metal, I should conceive that when the  surgeon means
  to resist the return of the protrusion, the latter should be preferred.
  In removing a hernia cerebri with the  knife, there is frequently pro-
  fuse hemorrhage;  but though copious  at first, certain cases on re-
  cord prove, that it stops after a short time, and is not itself produc-
  tive of  danger.  The liberties taken with the protruded portion of
  brain,  without any apparent ill consequences, are truly surprising:
  the facts demonstrate, at all events, that the superficial parts of the
  hemispheres will bear a great deal of  injury and mutilation,  without
  hfe being destroyed or recovery prevented.  We cannot wonder
  that this disease should be so  often fatal, when we remember, that,
  ;u most cases, ,t ,s complicated with extensive and deep-seated in!
 jury of the brain.  Dissection  shows,  that there is generally black-
 ness and sloughing of the dura mater for some extent around the tu-
 mor; and that   m} many cases, the substance1 of the brain has a
 softened and  broken-down  appearance.   A foetid  dark colored
 fluid ,s also found between the dura mater and arachnoid membrane
 which latter part is often thickened and opaque.         mem^ane,
   [In the N. Y. Journal of Med. and Surgery, No. 4,  1840   there i,
 a valuable paper upon hernia  cerebri by  Dr  Buck one of thp%
 geons of the N. Y. Hospital.   He analysed tLty-three  cases  and t^

 ^iXtZ™ ^ °^ —hat " "^itn^

^^^^^^^^ o^hea^r ,*'
^.nd not that there is any difference in ^eor^^^1^
 The  youngest subject was two and a half years old  thl l\ i  ♦ r
 Seventeen of the number were twelve and ifnder and  „L     c^'
 thirteen to twenty,  making twenty-six, out" onh^li^Tc^ 
           FUNGOUS  TUMORS  OF THE  DURA MATER.         3o

under twenty-one  years of age.   This shows, that we have a greater
tendency to fungus cerebri in young  subjects.  In twenty-one of the
cases, the dura mater was lacerated,  in ten there was no solution of
its continuity.  In fourteen,  the  brain  was wounded, and  portions
lorn away, in five,  it was wounded, but none torn away, and in ten,  it
was not seen, as the dura mater was  whole.
  The time when  the fungus commenced varied.  In six cases, it oc-
curred before the sixth day ;  in fifteen, between  the  seventh  and
twelfth ;  and  in five, between the twelfth and  twenty-fifth days, and
in one instance,  after  eight  weeks.  The earliest appearance of the
disease  was  on the  third  day, and more  than  three-fourths of the
hernia, occurred  before the  twelfth  day.   Seventeen recovered,  and
sixteen died.  Twelve of those who recovered  were  twelve  years old
and under, and only five of those who  died were less than twelve.
The size of  the tumor varied, from one inch and a  half in diameter,
to a mass measuring six inches by three and  a  half on the surface,
and two  and a half in thickness.  The tumors, in eleven  of the six-
teen  fatal cases  were examined; nine of them, were composed  of
the medullary and cortical substance of the brain and two of those
reported  by Mr. Abernethy, consisted of a coagulum of blood.
   From   this analysis of Dr. Buck we learn, that young subjects are
more exposed to fungus cerebri than old, probably because there is al-
wa)s a stronger tendency  to inflammation of the brain  in children.
We learn also that there is more  danger of hernia, when the dura ma-
ter is lacerated, and  the brain wounded.  We discover too, that the
tumor shews itself, generally, by  the  twelfth day, after the injury ; that
when the disease does occur, there is an even chance that  the patient
will recover; and that the younger the subject, the  better  the prog-
nosis.
   We learn, moreover, that the structure  of the tumor is cerebral  in
most instances,  and that there is no one course of local  treatment,
which can be relied upon in all cases.
   We entertain  the opinion, that the liability to the occurrence of
hernia, is always proportionate to the amount of general injury of the
brain.   We have  never yet  seen  a case of fungus  cerebri, however
 extensively the dura mater  and  brain were lacerated, except  when
there had been decided concussion.—Ed]


             FUNGOUS  TUMORS  OF  THE  DURA  MATER.

   Fungous tumors sometimes  grow from the external surface of the
dura mater, and,  after destroying the superincumbent portion of the
cranium, make  their  appearance in  the form of an  external swelling
under the scalp.  They are generally preceded by a blow, or fall
on the head, and  occur at the part to which the violence was applied.
 As the fungus grows larger, its pressure against the skull, and  par-
ticularly its pulsatory motion derived from that of the brain, occa-
 sion a slow and  gradual absorption of the  bone,  just in  the same 
 34      DISEASES OF  THE  EYE  AND  ITS APPENDAGES.

 way as  an aneurismal tumor  destroys  any part of a bone against
 which it happens to press.  The portion of the  cranium immediate-
 ly over the swelling being absorbed, the fungous excrescence meets
 with less resistance; it quickly protrudes through the opening in the
 skull;  forms  a prominent  tumor under the scalp; and enlarges  with
 increased rapidity.  The severe pains  in the head, which precede
 the external  appearance of the  disease, become still more violent
 as soon as the fungus  protrudes through  the opening  in  the bone,
 and is irritated by the sharp inequalities of its edge.  The swelling
 has a manifest pulsation, corresponding  to that of the arteries; and
 when compressed, it either returns entirely within the cranium, or is
 considerably  lessened.   The pain  then subsides, the tumor being
 no longer irritated by the irregular circumference of the opening  in
 the skull.  If the size of the fungus be large, no relief can be thus-
 obtained; for, when an endeavor  is made to reduce the tumor, all
 the alarming  symptoms of pressure on the brain are immediately ex-
 cited.
   Fungous tumors of the dura mater constitute a  very  dangerous
 form of  disease,  and mostly prove fatal.
   Before a fungus of this description has made its way through the
 cranium, and projected under  the scalp, so that  its  nature and exis-
 tence can be ascertained, the  practitioner has no opportunity of at-
 tacking the disease with any effectual means.   The ordinary treat-
 ment of  the severe pain occurring in certain parts of the head, after
 blows or falls on the cranium, and  before the fungus protrudes, has
 consisted of bleeding and  evacuations.   But when the disease has
 manifested itself in the form of an outward swelling, the  nature of
 which  is recognised from previous circumstances, as well as from
 the pain  which attends it, and  subsides on  its  reduction, and its  pul-
 satory  motion, the head should be shaved, a crucial incision made
 in the scalp  covering the  fungus, the angles dissected  up, and the
 whole of the tumor and the margin of the opening through which it
 protrudes fairly exposed.   But, as it is  impossible to get at the en-
 tire root  of the fungus, while it is closely embraced  by the cranium,
 it becomes necessary to saw away the surrounding bone.   This ob-
ject can  be best accomplished with one of Hey's saws.   The root
 of the fungus being thus exposed, the next business is to cut it away
 from the  dura mater.  Fungous tumors  of the dura mater have oc-
 casionally been extirpated with a ligature.  The first operation which
 I ever  saw in  St. Bartholomew's Hospital, was the excision of two
 or three of such tumors, which  was performed by the  late  Mr.
 Ramsden.   The  patient did not recover.
     DISEASES  OF THE  EYE  AND  ITS APPENDAGES.

This part  of surgery  being now cultivated  with minute c 
            DISEASES OF THE LACHRYMAL ORGANS.         35

surgeon/who values his own reputation, will neglect the study of it.
Were it not a subject  disfigured  by too many  harsh and barbarous
terms,  I should say, that it is one of the most inviting departments
of surgical pathology  and practice—one, in which we may often
actually see the changes of  disease exactly as they occur,  and esti-
mate their nature and character with wonderful precision.
   For  the sake of method,  I will  divide it into  three parts;  the
first comprising diseases of  the lachrmyal organs, the  second those
of the  eyelids, and the third the diseases of the  eye itself.
           DISEASES  OF THE  LACHRYMAL ORGANS.

   The  lachrymal gland is  not itself very liable to disease.   In
scrofulous children, it is occasionally  the seat of inflammation and
suppuration; but such a case is uncommon.   The proper treatment
would  be leeches, purgative medicines, a cold  evaporating lotion,
and other antjphlogistic  remedies.   If suppuration could not be pre-
vented, the cold  lotion  should be exchanged for poultices and  fo-
mentations;  and, as soon as matter had formed, a  puncture ought
to be made, if possible, through  the conjunctiva, under the outer
portion of the upper eyelid; or, if this were impracticable, through
the skin.
   Another disease is an indolent scrofulous enlargement oj the lach-
rymal  gland.   When  I speak of any  disease  of the lachrymal
gland,  the case, whatever it  may be, must be an  uncommon  one;
and this we shall  be convinced of when we hear, that  the  Reports
of the  London Opthalmic Infirmary, for  twelve successive years,
contain no example of any disease of the lachrymal gland.  If we
were to meet with an indolent enlargement of it, we ought  to  treat
it with the general remedies recommended for other scrofulous dis-
eases,  especially the  repeated use of leeches,  the compound calo-
mel pill at night,  and  aperient medicine  in  the morning; or,  what
might be  still  more advisable, we  should have recourse to friction
with iodine ointment, prepared  according to Lugol's  formula,  the
patient taking at the same time the  iodine solution, made according
to his  directions.
   Scirrhus of the lachrymal gland  is mentioned by most surgical
writers; but doubts are sometimes entertained, whether a certain chro-
nic induration of the  lachrymal gland, generally described  as scir-
rhous be  truly of this nature; for the disease is remarked not to af-
fect the  lymphatic system; never to undergo  malignant  or  can-
cerous  ulceration, independently of that of the eyelids or conjunc-
tiva; not to be followed by  relapse after extirpation;  and that the
lachrynal gland is not very  prone to  assume any malignant change,
 may be inferred  from the fact,  that when the globe  of  the eye and
the other contents of the orbit are extensively diseased,  the lachry- 
 36         DISEASES  OF THE LACHRYMAL ORGANS.

 mal gland usually remains unaffected.   The same fact is common-
 ly noticed in cases of medullary disease of the retina,  even when it
 has advanced to that degree  which makes the removal of the eye
 necessary.   The gland may be rendered as large as, or even lar-
 ger than, a walnut;  but when removed, its texture, though harden-
 ed, does not always exhibit the peculiarities of the schirrhous struc-
 ture.  However, the  best authorities  differ on  this  subject; for
 some of them  contend, that the lachrymal gland,  conjunctiva, and
 eyelids are the  parts about the eye  peculiarly liable to cancer; and
 there is no  doubt, that the lachrymal gland  is sometimes involved
 when these other parts  are  attacked.  A truly scirrhous affection
 of the lachrymal gland alone  is undoubtedly a rare disease.  In the
 examples, recorded  by  Mr.  Todd and  Dr. O'Beirne, the struc-
 ture of the diseased gland seems to have  corresponded to that or-
 dinarily described as characteristic of scirrhus.
   What is reputed to be scirrhus of the lachrymal gland, is not at-
 tended with  that preternatural  dryness of the eye  which has fre-
 quently been supposed to be  an unavoidable consequence of such a
 disease; for in  the cases of  it, recorded  by  Mr.  Todd  and Dr.
 O'Beirne, in the 3d vol. of the Dublin Hospital Reports, there was
 actually an increased secretion of  tears; an epiphora,  as it is tech-
 nically called.   The symptoms  characterising  it are, lancinating
 pain in the external and upper part of the  orbit;  enlargement of the
 gland, till  it  forms a  prominent, hard, lobulated,  tumor, quite per-
 ceptible under  the tense skin of the upper  eyelid,  and displacing
 the eye-ball  in a greater or less  degree, downwards, inwards, and
 forwards;  dulness of the cornea; dimness of  sight;  double vision;
 dilatation of pupil; and at length complete blindness.    In the worst
 stages, the temporal side of the orbit is dilated, or the eye so press-
 ed upon as to be destroyed by ulceration and  the evacuation of its
 humors.
   As  for the treatment, with the view of reducing  and dispersing
 what is termed  scirrhus  of the lachrymal gland, the means proposed
 are leeches, followed  by a succession of blisters, alternately to the
 neighboring   part of  the forehead and temple;  or friction  with
 Lugol's iodine  ointment,  assisted by  the internal exhibition of the
 iodine solution.
  Were these plans to prove ineffectual, and  the tumor to become
 a source of  considerable annoyance to the patient, or of mischief
 to the eye, it would be necessary  to  remove the diseased gland.
 The operation cannot be easily done from beneath the upper  eye-
lid, as it is  sometimes  recommended,  unless an incision be  made
through the  outer  commissure,  so as to  let  that eyelid be turned
completely up,  and the conjunctiva be sufficiently exposed.  Hence
surgeons, who have occasion  to remove the lachrymal  gland, have
generally preferred cutting directly down to the tumor,  making  a
crucial incision  over it, raising the  angles  of the wound, and then
taking hold of it with a tenaculum, and dissecting it out. 
DISEASES OF THE LACHRYMAL ORGANS.
37
   The return of vision, and of the eye into its place again, does not
always take place immediately;  and the sight may, indeed, never
be  recovered.  In one case,  reported by Dr. O'Beirne, the eye
resumed its  proper position, and vision was restored.   In another
instance, the particulars of which are  given by Mr.  Todd,  though
the protrusion of the eye was gradually rectified after the operation,
the blindness continued.   In one or two examples, which were un-
der Mr. Lawrence, the operation was  followed by a considerable
improvement of the sight.
   Diseases of the Caruncula Lachrymalis.—Thecaruncula  lachry-
malis and semilunar fold of the  conjunctiva are liable to inflamma-
tion, and sometimes matter collects in the substance of  the former.
The treatment consists in the removal of the cause,  which may be
the pressure  and irritation of the eyelashes, or the presence of some
extraneous substance;  but  the most common cause is exposure  to
cold.  The caruncula is to be frequently bathed with tepid water,
and opening medicines administered.  In the early  stage  of a severe
case, a leech might be put on the caruncula;  and, in the event of
suppuration, a bread and water poultice, included in a little muslin
bag.  The abscess should be opened early; and if fungous granula-
tions  arise, they are to be repressed with the  nitrate of  silver.
   Encanthis signifies a chronic enlargement of the  caruncula lachry-
malis.  Two forms of it are usually described;  one, a simple indolent
swelling of the part; the other, a scirrhous affection of it, disposed
to degenerate into  cancerous ulceration, but, fortunately, so rare that
some surgeons, who have had the greatest opportunities of seeing this
department of surgery, have not met with a single example of it.  The
inconveniences  necessarily  resulting  from an encanthis, are con-
siderable, as chronic ophthalmy, an impediment  to the complete
closure of the eye, and an  interruption of the passage of the tears
into the nose by the  compression and displacement  of  the  puncta
lachrymalia.   Hence the tears are  continually dropping over  the
cheek, so as  to  produce the complaint technically  named stillicidi-
um lachrymarum,  which is  not to be confounded with epiphora;
for while this last consists in so profuse a secretion from the lachry-
mal gland that the  tears cannot wholly pass down into the nose, the
stillicidium is a dropping of the  tears over the cheek, in  conse-
quence of an  impediment  to  their passage from  the eye into the
lachrymal sac.  From the various  causes, which I have explained
as accompanying encanthis, the eyesight itself must be considerably
weakened and disturbed.
   When  an  encanthis cannot be reduced by applying to  it the
vinous tincture of opium, or a solution of the nitrate of silver, and
especially when, from its great  pain and disposition  to bleed, it
evinces a cancerous tendency, or, at all events, a propensity to be-
come a very  painful and troublesome disease, it should be removed
without further delay.   Some operators pass  a ligature  through  it,
   VOL.  II.                4 
38         DISEASES OF THE LACHRYMAL ORGANS.

by means of which they draw it out,  while  they perform the requi-
site incisions  with a small scalpel; but  taking hold of it with a ten-
aculum will enable us to  cut it away  with facility.
  In the encanthis of the large inveterate kind, an  elongation  of it
upon the inside of each eyelid may be seen, requiring to be separat-
ed with the knife in the commencement of the operation, before the
main part of the tumor is  separated.   The surgeon should be careful
not to encroach upon the  conjunctiva, and, if possible he should save
a small portion of the caruncula, sufficient1 to prevent a perpetual
dribbling of the tears over the  cheek, after the cure of the disease.
The eye  is to be  bathed with tepid water, and afterwards  mild
ointments, and astringent  collyria,  &c, are to be employed.  If the
granulations rise too much, the nitrate of silver is to be applied.
  Of various Diseases of the Lachrymal Organs, formerly confound-
ed together under the Name of Fistula Lachrymalis.—It is only within
a few  years,  that any discrimination has been introduced into the
views taken by surgeons of the diseases of the  lachrymal organs.
Nearly all these complaints were supposed to be essentially connect-
ed with obstruction of the nasal  duct; and hence its removal was
generally the  principal thing contemplated in the  treatment.  It was
too much looked upon as a cause, and not as an  accidental accom-
paniment  or  consequence, of certain  affections of the  lachrymal
parts of the eye.   The truth is, obstruction of the nasal duct is
sometimes merely the temporary effect  of inflammation;  and, I
might  say, that in the  greater number of diseases affecting  these
parts, such obstruction either does not really exist, or, at all events,
has no share in the original production of the inconveniences which
the patient is experiencing.   Thus, if the disease be simply a  mor-
bid change in  the secretion of the  mucous lining of the  lachrymal
sac, the blennorrhea sacculi lachrymalis, as it is  termed,—or  if the
case be merely an extreme relaxation of the part, the hernia, of it,
as it is  sometimes called, the absurdity  of opening the  sac with  a
knife, and thrusting a probe, bougie, or style down into the nose,
must be obvious.
  Inflammation of the  lachrymal sac may extend, more or  less,
dowri it into the nasal duct.  The affection may be acute or chronic;
the latter being more  common than  the former.   In the  acute, a
swelling, shaped like a  horse-bean, and attended with a degree of
redness, presents  itself just below the tendon of the orbicularis pal-
pebrarum muscle.   The swelling of  the  skin is at first confined  to
the part over the lachrymal sac,  but  afterwards spreads to the eye-
lids, which present an oedematous  appearance.   Now,  in conse-
quence of the lining of the sac and nasal duct becoming thickened
die passage for the tears  into the nose is obstructed; so that, partly
from this cause, and partly from the  shrunk  contracted state of the
puncta  lachrymalia,  usually noticed at the same time, the tears  do
not descend  into the nose,  but fall over the cheek; consequently 
DISEASES  OF THE LACHRYMAL ORGANS.         39
there exists what is termed a stillicidium lachrymarum.  However
inflamed the skin may be, we may always distinctly feel the swelling
of the lachrymal sac beneath it.  In healthy individuals, this kind of
inflammation of the lachrymal sac rarely leads to the permanent ob-
literation of the nasal duct by the effusion of fibrine, though in scro-
fulous subjects such a result is  possible.
   The pain attending acute inflammation  of the lachrymal sac and
lining of the nasal duct, is more severe  than might be expected from
the small extent of the part affected.  The headache is excruciating,
and the fever  considerable.   Frequently the case advances to sup-
puration.   The sac, and the parts by which it is covered, being in-
capable  of any further  distention, sometimes slough; but, more
commonly, in the middle of the  swelling  a yellowish  soft point is
observed,  which  soon gives way.   Then, the collection of pus and
mucus within  the sac  makes its way through the orbicularis  palpe-
brarum and the integuments; but, by  this  opening, merely the thin-
ner parts of the matter are discharged,  and the tumor  is for a time
somewhat  lessened.   Soon afterwards,  when pressure  is made upon
the superior part of the sac, not only pus  and mucus are discharged
from the opening, but occasionally a quantity of pure tears; a proof,
at all events, that the conveyance of the  tears into  the sac is now
re-established.  In other words,  the action of the lachrymal puncta
and  canals has again  commenced.  This  is always a favorable cir-
cumstance, as it  denotes that now the  only question relates to the
state of the nasal  duct.    For some time after the discontinuance of
suppuration, a morbid secretion,  somewhat like pus, is kept up from
the mucous membrane of the sac; but  this also ceases in its turn,
and healthy mucus is again formed in  the natural quantity.   Some-
limes the opening in the sac now heals up either spontaneously or
by the aid of  common surgical treatment.    Most frequently it con-
tracts at first to a  very minute size, through which, if the nasal duct
should not have become  duly  pervious again, the tears and mucus
will occasionally be discharged.  Should this minute opening close,
and the nasal duct still remain impervious, the patient is obliged sev-
eral times in the day to press upon the sac, in order that the mucus
and tears collected in it may be discharged through  the  lachrymal
puncta and canals.  In other instances, the swelling of the lining of
the sac and duct lessens  with the inflammation; the  passage for the
tears is restored; and a complete cure is the result.
   From what has been stated,  it is manifest, that it  is not every in-
flammation of the lachrymal  sac that terminates in the production
of an external opening indisposed to heal, or a fistula  lachrymalis,
as it is termed.  Whether such an opening  form or not, and whether,
when formed, it will become fistulous  or not, will materially depend
upon the treatment.
   If, when the lachrymal sac is violently inflamed, the  case be neg-
lected or  wrongly managed, a complete or  partial  closure of the 
40         DISEASES OF  THE  LACHRYMAL ORGANS.

nasal duct by the adhesive  inflammation is  likely to be  the conse-
quence.   There may also be produced an  obliteration of the lach-
rymal canals, in which event, the absorption of  the tears, and their
conveyance from the eye into the sac, may be  for ever  impeded,
and the patient remain during the rest of his life afflicted with a stil-
licidium lachrymarum.
   In the first stage, the plain indication is to endeavor to subdue the
inflammation;  and it is by combating this affection, and not  by at-
tacking one, or even several of the symptoms,  or effects, that we
shall have the greatest success in  curing the patient.   For instance,
what would here be more absurd  than the  scheme of dilatation, by
the introduction of probes through the lachrymal canals into the sac,
or even through the nasal duct into the nose?  This would only be
subjecting the inflamed parts to a new cause of irritation, and in-
creasing the risk of greater mischief than is actually  impending.
Hence, instead of trying to insinuate instruments  from one  of the
puncta lachrymalia down into the nasal duct,—a method, as I think,
never advisable as a common practice, on  account of its injurious
effect upon the  delicate  organization of the  lachrymal puncta and
canals;   and,  as Dr. Mackenzie attests, rarely successful  in any
cases; we  should  have  immediate recourse to antiphlogistic treat-
ment; applying  leeches freely and repeatedly to the  inflamed part
and its vicinity,  covering it either with a cold evaporating lotion, or
applying poultices  and fomentations,  and  prescribing saline aperient
medicines, followed by the exhibition of  calomel, and  antimonial
powder.  A very low diet will always be requisite; and, when the
pain is severe, venesection.
   Two principles  I wish particularly  to inculcate:  1st, that it is not
every inflammation and temporary obstruction  of the  lachrymal sac
and  duct, which require the  introduction of instruments  down the
duct into the nose:  2d, that when the obstruction is permanent, we
should puncture the sac,  and  attack  the obstruction in this manner.
This is much better than throwing lotions into the  sac through the
lachrymal puncta and canals, whereby we  should be more likely to
destroy the right action of  these  delicate  organs,  than  remove the
stoppage of the flow of the contents of the sac into the nose.
   In the second stage, when resolution is no longer practicable, the
cold lotion may  be laid  aside for emollient applications;  and when
the sac is so distended with mucus  and  pus that  the centre of the
swelling begins  to soften,  and a fluctuation to be  perceptible  a
puncture should be made large enough for  the  ready discharge of
the contents of the sac.  Having made an opening, I would merely
inject tepid water with Anel's syrjnge down the nasal duct; a plan
which may be repeated every day, if the fluid can be made to pass
into the nose.  If it cannot, the obstruction should be removed with
a probe.
   When, by means of antiphlogistic treatment,  the inflammation of 
             DISEASES OF  THE  LACHRYMAL ORGANS.         41

the membrane of the sac has subsided, and by this and other mea-
sures the mucous secretion  from  it has been brought into a healthy
state, and all the induration  has disappeared, we may then  think of
adopting some plan for the  re-establishment of the passage through
the nasal duct, if it should not have already become free again un-
der the treatment here recommended.
   What I have now said principally relates to acute inflammation
of the lachrymal sac; but this part is still more liable to chronic in-
flammation.   Sometimes, and especially in scrofulous subjects, the
lachrymal sac becomes distended with mucus, without any previous
active inflammation in it.   This is the stage which Dupuytren calls
the lachrymal  tumor, and  which  begins almost imperceptibly, the
swelling being at  first  scarcely distinguishable, and  situated under
the inner canthus, and  below the tendon of the orbicular muscle.
It is circumscribed, and at first unattended with pain, or any change
of color in the skin.   The  inconvenience, first noticed,  is a weak-
ness of the eye, from the  tears collecting at  the  internal canthus.
Whenever the patient looks at minute objects, he finds a tear rea*
dy to drop over the cheek;  and, to relieve himself from this annoy-
ance, he  is obliged to press upon the  sac, so as  to expel its con-
tents,  which either regurgitate through the puncta, or,  what  is less
common, pass down into the nose.   In this case, the nostril is gen-*
erally drier than in the natural or healthy state of the lachrymal or«
gans.   Things go on in this way a considerable time, until at  length
the tears cannot any longer  be made  to descend by pressing upon
the tumor in the corner of the eye; but, instead of doing so, they
regurgitate entirely by the puncta lachrymalia, mixed with pus and
mucus,  and  the whole  of  the lachrymal  secretion  falls  over the
cheek.   The mucous membrane  of the sac is the chief seat of this
chronic inflammation.   Sometimes the lachrymal canals, the sac,
and the nasal duct are all affected together;  and occasionally the
lachrymal canals alone.  After a certain period,  the effects of the
inflammation generally extend, more or less, to the mucous mem-
brane of the eyelids,  and even to the eye  itself.   The edges  of the
former are swollen, and  adhere  together  in  the morning; and the
vessels of the conjunctiva are always more injected with blood than
in the  healthy state  of the  eye.   In many individuals,  the com-
plaint disappears during summer, but returns at the commencement
of cold or wet weather.
   The complaint may continue in the  above state for a long time;
but, at last, a period arrives, when the parietes of the tumor be-
come very  thin, when  the  swelling  can no longer be  emptied by
pressure, and the skin over  the sore is red, hot, and painful.   Fre-
quently the inflammation extends  to  the eyelids, cheek,  nose, and
forehead.  A fluctuation is  now felt in the tumor, which  points and
bursts; and the  opening, if  neglected,  is converted into a true fistu-
la lachrymalis.   In most patients, the stillicidium  lachrymarum  is 
42
DISEASES OF THE LACHRYMAL  ORGANS.
 now materially lessened, in consequence of the tears finding an out-
 let through the new opening, which the nasal duct did not previous-
 ly afford them.   The discharge from the sac  is a mixture of tears,
 mucus, and pus.
   The treatment of chronic inflammation of the lachrymal sac  con-
 sists  in endeavoring  to remove the  inflammation; and, if we  suc-
 ceed in this purpose early  enough, we prevent suppuration and ul-
 ceration of the  sac, the  formation of a fistula lachrymalis, as  it is
 called; the nasal duct will  not be permanently obstructed; and  the
 tears and mucus will gradually resume their proper course into the
 nostril.
   If, after the cure of the inflammation, the passage should not be
 free, and the sac remain distended, we may endeavor  to  press  the
 fluid, with which it is filled, down into the nostril, placing the  fin-
 ger for this purpose between the puncta and  the sac, and pressing
 from the  puncta towards the nose.   We may  also instil  into  the
 corner of the eye, every day or every second  day, a few drops of
 a lotion containing 2 grs.  of the nitrate of silver, or from 2 to 4
 grs. of the sulphate of zinc, to an ounce of distilled water; and in
 order that such  fluid may be absorbed by the lachrymal puncta, the
 patient should lie upon his  back, and continue quietly in this position
 during, and for a short time after, the operation.
   When the conjunctiva of the eyelids and the Meibomian  glands
 are affected,  we may employ  salves, the best of which are  the
 ointment  of the nitrate  of quicksilver,  in the proportion of one
 third of it to two thirds of spermaceti ointment; the red or white
 precipitate of mercury ointment in the proportion of one scruple of
 the powder to an ounce  of lard; or  the nitrate of silver ointment,
 from five  to ten  grains to an ounce.   Undoubtedly, when suppura-
 tion cannot be prevented, emollient poultices and  fomentations  are
 advisable; and,  as soon as  the abscess is distinctly formed, a punc«
 ture should be made in it.
  On examining the nasal  duct, we now generally find  it contract-
 ed at one or several points; and, for the removal of the obstruction,.
 we are next to  introduce  a probe, and then employ a nail-headed
 style, in order to remove the disposition of the  passage to close
 again.   This instrument may be worn for an unlimited time without
 any material annoyance.   The eyelids being drawn outwards, so as
 to put the orbicularis palpebrarum on the stretch, we are to make
 a puncture in the sac with a lancet, or a  narrow sharp-pointed  bis-
 toury, along the  surface of  whose blade the style will pass into  the
 sac, as on a director; a convenient method, which,  I observe  was
practiced by Dupuytren, with  his  cannula, and which I have'seen
 Mr. Liston adopt, in University College Hospital, with great skill,
as soon as the puncture had been made.   It is the method to which
I usually  give  the  preference.  Before making the puncture,  we
ascertain the precise situation of the nasal edge  of the orbit  and of 
DISEASES  OF THE  LACHRYMAL ORGANS.
43
 the tendon of the orbicular muscle: for it is between these points
 that the knife should be introduced, carefully avoiding to go below
 the margin of the orbit, where the sac will  not  be found: a large
 quantity of mucus and puriform matter will be immediately discharg-
 ed.   A common silver probe is then to be passed into the sac, and
 thence down the nasal duct into the nostril, so as to clear away the
 obstruction.   It  should  be introduced horizontally, till it touches
 the nasal side of the  sac; it should then be raised into a vertical
 position, and its  point directed downwards  and  a little backwards.
 If it meet with an obstruction, we must not immediately conclude,
 that there is an obliteration of the duct; but should press the probe
 down a little more strongly, turning it round between the  fingers,
 and giving it  different  directions.   In this way, the obstacle may
 frequently be overcome, and the probe will suddenly descend.  The
 probe is  then to be withdrawn,  and a little tepid water (injected;
 after which the style is to  be introduced sufficiently far to bring its
 head*in contact with the skin.   I  see  no  utility in making  a formal
 extensive incision: all that is required  is a puncture to  let out the
 matter, and to allow the style to be introduced, which is to be with-
 drawn, once or twice a week, and tepid water, or some slightly as-
 tringent lotion, injected through the nasal duct.
   After the style has been worn a little time the blennorrhea of the
 sac, as it  is  termed, disappears almost entirely.   The tears and
 mucus, absorbed  by  the lachrymal canals,  would seem to  be con-
 veyed along its surface through the nasal duct; and  thus the func-
 tions of the parts being  restored, the  inflammation and discharge
 quickly subside.  The curious fact of the fluid taking its natural
 course, when a solid   style is thus kept  in the nasal  duct, seems to
 Mr. Lawrence to be explained by what  happens  in the urethra;
 namely, by the enlargement of that canal  round  a  catheter, which
 is left in it.
   Sometimes, after  the style  has been worn one,  two, or three
 months, it is discontinued, and the opening heals up; but a relapse
 takes place, and  it is necessary  to introduce the style again, and to
 continue it for some weeks longer.   What proves how little incon-
 venience is commonly  felt from its presence is, that the patient will
 often express a preference to wearing it  a very  long  time, rather
 than subject himself to the slightest  chance of a  return of  the dis-
 order.
   When the head of the style is covered with black sealing wax it
causes little or no disfigurement.   The instrument must occasionally
be taken out and cleaned.   After the parts  have become habituated
to it, I find that  taking it  out once a-week is quite sufficient.   If
left in too long, without  being cleaned, it would be  corroded, and
likely to break in  the part.
  When the style, on being first used,  creates much irritation, it is
better to withdraw it, and  after clearing away all  obstruction in the 
44         DISEASES  OF THE  LACHRYMAL ORGANS.
nasal duct once more with a probe, we are to be content  with in-
jecting tepid water through the nasal duct by means of Anel's syr-
inge, using at the same time leeches, emollient applications, and ape-
rient medicines.   Instead of a style, a tube made of gold, or silver,
is employed by some practitioners.   Baron  Dupuytren prefers a
tube of this kind, which  is introduced  into the nasal duct by means
of a steel stilet, bent at a right angle at the portion beyond the bend
corresponding to the cavity of the tube.   The latter must  be fairly
lodged  in the  duct, with its upper or  expanded  portion occupying
the lower part of the sac.  The puncture soon heals, and  the tube
serves as an artificial channel for the  tears.   It  is calculated, that
Dupuytren treated 3000 cases in this way, and that, in  nine out of
every ten,  the cure was  accomplished, without any inconvenience
from the continuance of the tube in the duct.  In some instances,
however, it became displaced, rising  too high, or sinking  into  the
nostril,  through the lower opening  of  the  duct.  The first occur-
rence brings on inflammation, ulceration, and abscess, which reader
the extraction  of the tube necessary.   The second inflames and ir-
ritates the mucous membrane of the nostrils, and  sometimes excites
ulceration and sloughing  of it, and  the end  of the tube may  even
perforate the roof of the mouth.   Dupuytren has suggested very
good plans for extracting the tube  in each of these events;  but as>
the style, preferred  in this country, is not liable to the inconvenient
consequences here specified, I need not enter into  any  further de*
tails.
   When a  probe cannot  be got through the obstruction in the nasal
duct at  the first trial, a piece of catgut, ar  bougie,  may be left in
the passage, and the  attempt to overcome  the stoppage daily repeat-
ed.   If the obliterated portion of the nasal duct should still prevent
success, perhaps the right  practice  would be that of rendering  the-
nasal duct pervious again, by means of a small triangular  perforator.
This,  I think, would be better than drilling a hole in the os'unguis,
and  removing any portion of this bone with forceps, or  destroying
it with the  cautery.   If the perforated part of the duct  should not
admit of being kept open after the style has been worn a long time,
the patient must continue to wear either it or a silver or  gold  tube.
Caries  of the os  unguis,  so  frequent  formerly,  is now rarely met
with, a proof that it  was generally occasioned by wrong treatment.
In the Legons Orales of Baron Dupuytren is an instance, however,
where such caries took place,  even before the lachrymal tumor had
burst, or any fistula  had  been formed.
   With respect to general treatment.—In scrofulous cases, chronic
inflammation of the lining of the sac and nasal duct will  sometimes
not  yield,  unless  an  attempt  be made  to  improve  the state of the
constitution, by alteratives, tonics, especially the sulphate of quinine
and iodine medicines.  We may also  usefully combine with such
treatment blisters behind the  ears, or a seton in the nape of the 
DISEASES OF THE LACHRYMAL  ORGANS.
45
neck, and  iodine lotions, according to the  formulae given by Dr.
Lugol.
   Obstruction of the Puncta Lachrymalia and Lachrymal Canals.—
The puncta lachrymalia are sometimes congenitally deficient;  such
a case is hopeless.   Sometimes the puncta and canals are constrict-
ed, but pervious; and occasionally they become  blocked up  with
calcareous matter deposited  from the tears.   The most frequent
cause  of their obstruction  is a  thickening of the membrane lining
them,  a consequence of previous inflammation.
   When calcareous matter is present, it must be removed, as soon
as  its presence  has been  detected,  by  means of Anel's probes,
made  expressly for the purpose of examining  the  lachrymal puncta
and ducts,  and  for  removing any slight obstruction  in  them.
When they are stopped up with mucus,  they  may, with  these in-1
struments, easily be made pervious  again.   In examining  the su-
perior punctum and  lachrymal  duct,  we are to  introduce the  point
of the probe first from  below upwards, till  it  reaches  the angle of
the canal.   It is then to be directed  circularly downwards and in-
wards.  In examining the inferior duct, we are to direct the  point
of the probe  first  from above downwards, and  then  horizontally
towards the sac.
   When,  with these instruments, we cannot decidedly make out
 whether there  is an obstruction  in the puncta  or  not, we may put
 into the lacus lachrymarum a drop of an aqueous solution of saffron,
 while the patient lies upon  his  back.   If  the  canals  execute  their
 office, this  colored fluid  will  disappear, without  falling over the
 cheek.
   When the puncta and canals  are completely obliterated, the case
 is irremediable;  for, were  we to think of forming new puncta and
ducts we could  not give  them the  organisation essential to  make
 them of any use.
    Sometimes  cases present themselves, in  which  a stillicidium
 lachrymarum  arises from  atony and relaxation of  the  lachrymal
 puncta  and canals, in consequence of previous  inflammations, or
 the too frequent irritation of them with probes and syringes.  The
 puncta are seen  to be  widely open, and incapable of  contraction.
    For the cure of this form of disease, an  astringent collyrium,
 made  of  distilled water and a  small proportion  of the sulphate of
 iron, and camphorated spirit, or the tinct. opii, is  to be dropped out
 of a pen, or director, into the inner  angle,  frequently in the course
 of the day;  the patient  being  kept for some time on his back after
 each application.
    In  old persons, this kind of stillicidium is attended with more or
 less separation of the lower eyelid from the eye.   It may be some-
 what  relieved by astringent collyria: but never admits of a perfect
 cure. 
46
DISEASES OF  THE EYELIDS.
             DISEASES  OF THE  EYELIDS.

  Inflammation of the eyelids is not so disposed to involve the eye-
ball, as external inflammation of  the latter is to extend itself to the
former.   However, if the inflammation of the eye be restricted to
its internal textures, then the eyelids are not affected.   When ab-
scesses form  in the cellular tissue of the eyelids, an  early opening
should be made in them, as the most likely means of preventing the
extension of  the disease, and subsequent  eversion of the  part.
Passing over  wounds, phlegmonous and  erysipelatous inflammation
of the eyelids, the treatment of which is regulated by general prin-
ciples, I shall first consider—

        CATARRHAL INFLAMMATION OF THE  EYELIDS,

Which  affects their mucous  membrane  and  the glands  of  Meibo-
mius, and begins near the margins of the eyelids, which becomes
sore,  and are affected with heat and dryness.   Their lining assumes
a red, thickened,  and villous appearance,  and, if everted, looks
like a piece of scarlet velvet.  When the eyelids  are moved, the
pain is severe, because then  the inflamed surface rubs  against the
globe of the  eye; and  hence,  in every severe case, the  patient
keeps the eye more or less shut, and the eyelids motionless.   In
the beginning  of the attack, the natural mucous secretion is'suppress-
ed, and a sensation of dryness and stiffness is experienced;  but, af-
ter  a little while, this feeling  subsides, because now the secretion of
mucus recommences, and is even more abundant than natural, though
altered in quality, and somewhat  like pus.   The secretion from the
Meibomian glands is  also changed, so that it has a share in  making
the eyelids stick together in the night, and in the  morning  the patient
cannot open his eye.
  Catarrhal  inflammation of the  eyelids is mostly produced by at-
mospheric causes, and such as usually bring on inflammation of oth-
er mucous  membranes.   Bu{ inflammation  of the lining of these
parts  is  sometimes owing to its being habitually exposed  to the irri-
tation of smoke, or of an atmosphere impregnated with gas or va-
por of a stimulating kind, minute particles of lime, &c.   The influ-
ence of any of these causes will  be  rendered more powerful, if the
patient be uncleanly or intemperate.
  In  the early stage, during which the inflammation is always more
or less acute, antiphlogistic remedies are proper, as leeches, tepid
lotions,  and the unguentum cetacei, to the edges of the eyelids, in
order to keep them from becoming adherent in the night time.  The
oowels are to be kept well open; and, at first, some brisk purgative
medicine should be given.   These means,  if the  case  be one  of 
DISEASES  OF THE  EYELIDS.
47
Sufficient severity, are to be followed up by a blister on the nape of
the neck.   When the acute form of the  complaint has  been sub-
dued, we are to employ astringent lotions, and stimulating applica-
tions, especially the vinurn opii, and the ung. hydrarg. nitratis, which
latter is to  be  melted, and put  on the  edges of the eyelids with  a
camel-hair pencil.   At first, it ought to be weakened with an equal
quantity of the ung. cetacei.
           OPTHALMIA TARSI,  OR  PSOROPHTHALMIA,

Is merely a chronic inflammation of the lining of the eyelids, or ra-
ther of their margins, occasioning  their adhesion  together  in  the
night, a degree of soreness and itching in the parts, and a falling off
of the eyelashes.  The  Meibomian glands are considerably impli-
cated.  When the lining of the  eyelids has been frequently  in  the
state of chronic  inflammation, especially in old  subjects, not only
are  the  eyelashes lost,  but the  edges  of  the  lids,  instead  of
being  angular, become rounded, and  present an  habitually raw
and red appearance, which is technically named  lippitudo or blear-
edness.
   When ophthalmia tarsi has continued  for a  long while, or been
neglected,  the orifices of the ducts  of the  Meibomian glands, plac-
ed  along the inner margin of one or both eyelids,  may be partially
or totally obliterated;  and  it  is  chiefly in  such examples  that the
eyelashes  are  lost,  and the edges  of  the lids are  rounded  off.
Sometimes an eversion of the  lower eyelid  takes place,  from  a
contraction of the frequently excoriated  parts of the adjoining skin
of the cheek, or  an inversion of the part, from  the effect of previ-
ous ulcerations on the inside of  it.
   When a person is troubled with ophthalmia tarsi, or psorophthal-
my, he should never attempt to  open his eyes in the morning till the
glutinous matter,  which makes the eyelids and  eyelashes adhere to-
gether, has been properly  softened  and  dissolved,  so that  it  may
be done without pain.   For this  purpose,  the margins of the eye-
lids and the eyelashes should be anointed  with a small  quantity of
spermaceti cerate.  Then a piece of soft sponge, wrung out of hot
water, is to be held over  the eyelids for a few minutes, after which
the eye may be opened  without  pain.   All  the gummy  matter
should be tenderly removed, because, so long as it remains,  no eye-
water nor salve can be brought in contact  with  the principal seats
of the complaint.
   The first indication, or that of diminishing  inflammation, may be
further promoted by fomenting the  eyelids with a decoction of cam-
omile flowers, applying leeches to  the eyelids, and giving aperient
medicines.
   In bad  cases, the eyelids may be covered at night with a bread 
48
DISEASES  OF THE  EYELIDS.
and water poultice, included in  a bag  of fine muslin,  the margins
of the eyelids being first smeared with a little spermaceti ointment.
   The second indication, or that of healing the ulcerated  or exco-
riated parts of the lid, is fulfilled by applying  to them  the unguen-
tum hydrargyri nitratis, more or less weakened  at first with a  pro-
portion of lard;  or salves containing the red or white precipitate of
mercury, in the proportion of 10 or 12 grains of the former, or 30
grains of the latter, to an ounce of lard.
   When small ulcerations are noticed along the margins of the  eye-
lids, they are to  be touched with the nitrate  of silver, or a strong
solution of it; and, in bad cases, it is best before using the caustic,
to extract the eyelashes, for  if their  bulbs are  suffered to  be de-
stroyed by the ulceration, they will not be reproduced.
   The third indication, or that  of improving the general health, re-
quires employment of tonic  and alterative medicines, sea  bathing,
pure  air, and regular exercise.
                 THE  HORDEOLUM,  OR STYE,

Is generally compared to a little boil, of about the size of a barley-
corn, projecting from the eyelid.  It is of a deep red color, attend-
ed at first with itching, and afterwards with a considerable tender-
ness, and even more pain than  might be  expected from so trivial
a swelling.  Sometimes the irritation  is such that the  conjunctiva
is partially inflamed, and  the  motion  of the  eyelid  productive of
great annoyance.  It is the nature of a sty to suppurate very slowly;
but at length it  does suppurate,  points,  and bursts;  and after  dis-
charging a minute quantity of curdy  matter and disorganised cellu-
lar membrane, it usually subsides and disappears.   But if any of
the sloughy  matter  remain within it, the disease is  apt to return,
or to degenerate into a hard, white, chronic tumor, that is very  slow
in undergoing  any change,  and is technically named  grando,  from
having been compared  to  a  hailstone.  Young persons  are  often
annoyed for several  weeks by a succession of styes, one forming as
soon as another is cured.
   In the beginning,  cold applications, as the lotio plumbi acetatis,
or a cold bread poultice, made  with the same, or iced water may
be tried, though we rarely succeed in dispersing  the swelling altoge-
ther in  this way.  However, we may first try  what  cold applica-
tions and aperient medicines  will do; and when suppuration is  ob-
viously taking place, exchange them for warm poultices and fomen-
tations.   As soon as we see a white speck on the apex of the  little
tumor, provided the  tumor is slow in bursting of itself, we may make
a small puncture in it; but this should  not be done unnecessarily, or
prematurely, as it would only increase the inflammation, without ob-
taining any discharge  of the  contents of the sty.   The pus  and 
         ECTROPIUM, OR EVERSION OF  THE  EYELIDS.      49

sloughy cellular substance are then to be  pressed  out, and a poul-
tice  applied again.   When the  sloughy  cellular membrane is very
slow in coming out, the cavity  may be touched with lunar caustic,
or with the end  of a probe dipped in  sulphuric acid.
   The best way of treating the  tumor, termed grando or chalazion,
is to open  it, press out its contents,  and touch  the interior  of  the
cyst with lunar caustic, scraped to a point.

             ENCYSTED  TUMORS OF THE EYELIDS

Are not unfrequent, their seat  being generally in the cellular tissue,
connecting the  integuments of  the lid  with the orbicular  muscle ;
bui; they may be more deeply placed, so as to be covered not only
by the  orbicularis,  but  by the levator muscle.   The  more fluid
kinds sometimes grow to  the size of a pigeon's  egg; but the  steato-
matous ones rarely become larger than a filbert.   They  often con-
tain, besides the ordinary matter of encysted swellings, small short
hairs, entirely destitute of bulbs and tubes.
   The encysted swellings,  not closely connected with the  tarsal
cartilage, are to be treated precisely on the same principles which
apply to ordinary swellings of a similar character in other situations;
but  if they should be  intimately connected  with the cartilage, a for-
mal  dissection of them out would be  difficult without cutting a por-
tion  of the cartilage away.   Such operation may  be rendered  un-
necessary, by everting the eyelid, and making at the  point where it
appears to be thin and  most closely connected with the base of the
swelling a  free  puncture  through the cartilage, by which  the con-
tents of the swelling,  if fluid, will be discharged, but if found not to
be fluid, a second cut may be made across  the first  and the four  an-
gular flaps  snipped off with scissors.

         ECTROPIUM,  OR EVERSION  OF  THE   EYELIDS,

Is a  case productive of vast annoyance and considerable  disfigure-
ment.   The lower eyelid is most frequently affected, its edge fall-
ing downwards and forwards away  from the eyeball,  which  is  no
longer duly covered and  protected.   This exposure of the lower
portion of the eye,  and of the conjunctiva  of the eyelid,  produces
in these parts  a degree  of  inflammation,  attended  with  constant
pain and redness,  and  thickening of the  membrane, which  is at
length  converted into  a  hard callous substance, lying just under  the
eyeball.  As the flow of tears,  towards the inner angle, and through
the puncta lachrymalia,  is also obstructed,  they fall  over the cheek,
which  is apt to become excoriated.
   Ectropium  may arise  from various causes,  which considerably
influence the treatment; for it may be either a permanent or  only a
temporary deformity,  which will subside of itself on the abatement
   VOL.  II.                   5 
 50              [DISEASES OF  THE EYELIDS.

 of the inflammation that has given rise to it.   Thus we meet  with
 ectropium from acute inflammation of the conjunctiva.  When it
 affects the upper lid, it is in some degree accidental.  A child, for
 example, is laboring under acute purulent ophthalmy, and the sur-
 geon, in order to examine the eye,  or remove the copious discharge,
 everts the upper eyelid; the child  begins  to cry  violently, and all
 attempts  to reduce the lid  to its natural position are found to be in-
 effectual.  It soon becomes greatly distended with blood; and even
 if it admit of being  replaced, it  is generally everted again  as soon
 as the child begins to cry.  When this variety of ectropium affects
 the lower eyelid, it is not produced in this accidental way, but by
 the swelling and protrusion  of the inflamed conjunctiva.
   The treatment of ectropium from acute inflammation of the con-
junctiva requires,  1st, scarification of the everted conjunctiva; 2d,
 after  the swelling of the eyelids has been lessened by the discharge
 of blood,  the part may generally  be reduced;  3d,  if the inflamma-
 tion be not very acute, the  lid is  to be kept frorn^quitting its natural
 position by means of a compress and roller.  In the contrary case,
 every thing must be avoided likely to make the child cry;  and the
 attendants are to be instructed how  to replace the eyelid, if it should
happen to become  everted  again.  A collyrium  containing alum,
the nitrate of  silver, or sulphate of copper, must be applied  fre-
quently, for the purpose of checking the purulent discharge.
   When scarifications fail to  remove  or prevent the eversion, we
may cut away a portion of  the swollen conjunctiva.   The bleeding
which follows will  prove of great service.   Afterwards strips of
plaster passed from the upper to  the lower lid, and a compress and
bandage,  will prevent the return  of the displacement.
   Ectropium oj the lower eyelid from relaxation is most frequent in
elderly  persons, as a  consequence of chronic inflammation of the
conjunctiva  and  Meibomian  glands.  From  constant  exposure,
the inside of the everted lid  becomes red, firm, and almost  insensi-
ble, and the lower punctum lachrymale displaced forwards.  These
various circumstances are necessarily productive of a weeping of the
eye, a stillicidium lachrymarum,  and of various  degrees  of  inflam-
mation of the eyeball itself.
   The treatment  of ectropium of the lower eyelid from relaxation,
consists, first, in removing the inflamed state of the eyelids and con-
junctiva, and then  in  applying escharotics to the  exposed conjunc-
tiva, for  the purpose  of obviating the tendency  to  a return  of the
displacement.  After having scarified the  inflamed conjunctiva, we
may apply the sulphate of  copper, or nitrate of silver, and  a com-
press and roller.   In  inveterate  cases, a portion of the thickened
and relaxed conjunctiva is to be removed.
  Ectropium  of the lower eyelid, consequent to excoriation of it and
the cheek, resulting from long-continued ophthalmia tarsi or lippi-
tudo, is one of the most common forms of the  disease.   The pal- 
         ECTROPIUM,  OF  EVERSION OF  THE  EYELIDS.      51

pebral conjunctiva becomes thickened by long-continued and  re-
peated inflammation;  while the skin  excoriated,  or even ulcerated,
shrinks, becomes shortened, and thus draws the edge of the lid out-
wards.   In this case, the edges of the lid  are rounded off, the ori-
fices of the Meibomian glands partially or  completely  obliterated,
the eyelashes destroyed, and a considerable portion of inflamed con-
junctiva exposed to view.   The  ophthalmia tarsi is to be removed
by the means already explained.   For the  removal  of the chronic
lippitudo,  Mr.  Lawrence finds  that no application  answers better
than the  red precipitate  ointment, which may be freely applied to
the thickened and everted surface, as well  as to the  ciliary margin
of the lid.   It  reduces the swelling of the conjunctiva, and rectifies
the secretion of the tarsal glands.    Ectropium, even when accom-
panied with much thickening of the conjunctiva, may  be remedied
in this  manner.   In  more  obstinate cases, the  skin of the everted
lid is to be smeared with zinc ointment, and the exposed conjunc-
tiva  scarified  and  touched  with nitrate  of silver.  Should  these
means not prove effectual, a portion of the conjunctiva must be re-
moved.   In bad cases, resisting this treatment, the practice of cut-
ting out a  portion of  the  cartilage of the  shape of the  letter V is
sometimes adopted.
   Ectropium of the  lower eyelid from disunion of it from the up-
per one at the temporal angle is seldom seen, except in old persons
who have  been  long  afflicted with  inflammation of the margins of
the eyelids, and have had a succession of ulcers near the outer com-
missure.   The treatment requires an operation  similar in principle
to that performed for the cure of harelip, namely,—the edges of the
disunited commissure are to  be cut off, and the  parts  then brought
together by means of a suture.   The diseased state of the eyelids,
however, should be first previously removed.
   Ectropium from the contraction of a cicatrix.—The deformity is
not an unfrequent consequence of a  wound, an  abscess, an  ulcer,
or a burn.   In slight  cases, the simple operation of removing a fold
of the conjunctiva may  be  sufficient; but  some examples are met
with, in  which the degree of eversion is very great, the length of
the eyelid  in the transverse  direction much increased, and  its outer
surface fixed by adhesions.   Here the cicatrix must first be divided,
in order to loosen the lid  from  its unnatural position, and  then a por-
tion of the conjunctiva is to be  removed; but, for the  purpose of
counteracting the morbid elongation of the lid from one canthus to
the other,  it is  sometimes  necessary to  remove a  portion  of  the
whole thickness of the tarsal cartilage, shaped like the letter V, and
then to bring the edges of the wound together with a  suture.   Or,
in some  examples, we might imitate  Jaeger in completely detaching
the everted eyelid from the cheek, or superciliary ridge, leaving it
connected at the angles only.  The details of this operation may be
found  in  Mr.  Lawrence's " Treatise on  Diseases  of the Eye."
p. 350. 
52
DISEASES  OF THE  EYELIDS.
                          ENTR0PIUM.

   Amongst the numerous diseases of the eyelids,  I  have next to
explain one which is exactly the reverse  of the preceding;  namely,
entropium, or enversion of the eyelids, which is mostly seen in  old
subjects, in whom the skin of these parts  is loose and redundant,
destitute  of a proper  degree  of elasticity, and thrown into folds.
When the upper eyelid is inverted in the slightest degree, a consid-
erable irritation of the  eye is produced;  but when a large portion of
it is so displaced, the case becomes truly afflicting.    The  friction
of the eyelashes against the eye is incessant, attended with immense
suffering;  the eye itself inflames, the cornea  ulcerates, or becomes
opaque, and the eyesight is ultimately destroyed.
   The inversion may be  either temporary or permanent, the former
chiefly affecting the lower lid, and occurring in chronic  external oph-
thalmia, or sometimes even more acute cases.  The ciliary margin
becomes contracted from repeated inflammation; a spasmodic  ac-
tion of the orbicular muscle is produced, and the eyelid being thus
forced inwards, retains its unnatural position.  The temporary  in-
version may  be generally remedied by  putting a small compress
against the lower portion  of the eyelid, and fixing it  there  with  ad-
hesive plaster, placed transversely over it.   If this plan be contin-
ued for twelve or twenty-four  hours,  the inversion will not return.
   Permanent entropium   may  be mostly cured by cutting  away a
fold of the integuments near the edge of  the  tarsus.   We first take
up a  portion of them with the  entropium  forceps,  and  observe
whether what we hold is  sufficient to  bring the eyelid into its right
position; if so, we  cut it off with a small  pair of curved scissors,
and unite the edges of the wound  with  one or two sutures, which
may   be  withdrawn  the  next  day, as the wound  will then have
united.
   Another mode of cure is that of producing a contraction of  the
skin of the eyelid, by  cautiously applying across its central part a
little sulphuric acid,  by means  of a thin  bit of wood  dipped in it,
and rubbed upon an oval space a little  longer than the  extent of  the
inversion, and  from three to six lines in  breadth.  Three or four
applications will generally suffice.
   But more difficult cases sometimes arise from an alteration in  the
shape of the  cartilage of the eyelid.   For these, the common plans
will not answer, and we  must try others.  One consists in  making
two perpendicular incisions in the broad margin of the  tarsus, at  the
sides  of the inverted part, and then making a transverse cut through
the lining of the  eyelid, from the extremity of one of the first
wounds to  that of the  other.    The inverted  portion  of cartilage
thus comprised within the incisions, is  then to be put  into its right
position,  and retained in it with sticking plaster. 
TRICHIASIS
--PTOSIS.
  When the vicious shape of the tarsal cartilage makes the adapta-
tion of it to the eye impracticable, its  total excision has  been oc-
casionally performed.
  Sometimes it seems as if entropium depended upon the cartilage
being too short;  for if a cut be made through  the  outer  commis-
sure, the eyelid no longer presses against the eye.  Another opera-
tion, adopted by Jaeger, of Vienna, consists  in paring  away the
edge of the inverted tarsus.

                           TRICHIASIS

Signifies the growth of the eyelashes in such a  direction, that  they
rub against  and irritate the eyeball.
   We seldom  find all  the eyelashes turned towards the eyeball, ex-
cept when  trichiasis  is really accompanied by  an  inversion of the
eyelid itself.   The inconveniences of the complaint are severe; for
the friction  of  the eyelashes against the eye brings on inflammation
of that organ,  and, in time, and  under neglect,  opacity of the cor-
nea and  blindness.  The  wrong direction  of  one or more of the
eyelashes is often overlooked, and the effect, the inflammation, on-
ly attended  to: but here, as in  every  other  part  of  surgery, we
should search for the cause of the disease, and  not  disregard  it in
the treatment;  for its removal will alone frequently suffice to bring
about a cure.
   One plan of treatment consists in removing, one after the other,
all the inverted cilia by means of forceps.  Each eyelash  is  to be
laid hold of as close as possible to the skin,  and pulled out quickly
in a straight direction; but, in general, the result is only a tempo-
rary relief, as  the  hairs grow again.   Hence,   I believe,  the best
way is to pare  oft' as  much of the ciliary margin of the eyelid as
will include the bulbs of the inverted eyelashes.
  When trichiasis  is merely an  effect of entropium, the eyelashes
need not  be extracted, as the cure is  brought about by  the mea-
sures applicable to the entropium.
   Distichiasis  means a double row of eyelashes; but,  in  fact, the
supernumerary cilia are  never arranged  in  this regular order;  nor
do they usually extend the whole  length  of the eyelid, but  are scat-
tered at different points, between  the natural place of the eyelashes
and  the orifices of the  Meibomian glands.   Cases also sometimes
present themselves, in which strong hairs grow from the inner con-
cave surface of the eyelids.
   The only effectual mode of treatment is to extract the hairs and
their bulbs.

                            PTOSIS.

  An  inability to raise  the upper eyelid, which hangs loose and
                            5* 
54
DISEASES OF THE EYELIDS.
pendulous over the globe of the eye.   In some examples, this de-
pends upon  excessive  distension   and inflammation; but what  is
more commonly understood by  ptosis is that  form of it, which  is
accompanied  by paralysis of  the  levator  palpebral superioris.   If
the eyelid be lifted from the eye, it gradually  sinks down again  by
its own gravity,  being often  slightly oedematous, the eye looking
dull,  the iris being less irritable than natural, the pupil dilated, and
the eye frequently amaurotic.
   Ptosis is generally symptomatic of disease  of the brain, and the
treatment must be regulated accordingly.   With due attention  to
the cause, however,  there is no objection to rubbing the eyelid with
camphorated  mercurial ointment, or with  liniments containing am-
monia or camphor, or to blistering the neighboring part of the fore-
head.

           PARALYSIS OF  THE ORBICULAR  BIUSCLE

Sometimes follows operations  performed near  the lower  extremity
of the parotid gland, and  producing injury of the  branches  of the
portio dura of the seventh  pair of nerves.  So  far as  the eye  is
concerned, the consequences are not usually serious, and the incon-
venience is that of not  being able  completely to  shut the  eye; a
state, to which the term lagophthalmos is applied, whether arising
from  palsy of the  orbicular muscle, or a shortening or retraction  of
the upper eyelid itself.  However, lagophthalmos, when it exists
in a  considerable  degree, may bring  on inflammation of the con-
junctiva, opacity of the cornea,  and even staphyloma.
                   GRANULAR CONJUNCTIVA

Is mostly  an  effect of severe purulent ophthalmy, and consists of
a rough, hard, granulated state of the lining of the eyelid, attended
with a thin  or puriform discharge, a varicose affection of the vessels
of the sclerotic conjunctiva an increased vascularity and opaque  ap-
pearance of the cornea, great tenderness of the  eye, and  an inces-
sant  epiphora,  or copious effusion of tears.   The mechanical fric-
tion of the granulations against the cornea, has the effect of chang-
ing the  texture of the delicate  layer of the conjunctiva extended
over it.   In recent cases, leeches may be  applied near the eye, and
other means adopted to lessen  inflammation of the organ.   Then the
granular surface of the eyelid is to be smeared with the melted ung.
hydr. nitratis, or  a strong  solution of  the  nitrate of silver, twenty
or thirty  grains to one ounce  of water, by means of  a camel-hair
pencil, or rubbed  with the sulphate of copper, or nitrate  of silver.
For this purpose, the eyelid should always  be completely evertedj
as there is  sometimes a semilunar fringed  excrescence at  the angle 
DISEASES  OF THE EYE.
55
where the conjunctiva passes from the globe  to  the eyelid, which
might otherwise escape attention.   After caustic has been used, the
eyelid must be bathed with tepid water before it is returned into its
natural position again.
   Sometimes, when the granular productions are remarkably  hard,
callous, and pendulous, excision is preferred.

                 CONCRETION OF  THE EYELIDS.

   Two varieties are  met with:  in one, the  inside of one or  both
eyelids is adherent to the eyeball (symblepharon);  in the other, the
edges of the two eyelids are connected together (anchyloblepharon).
This last case is sometimes,  though rarely, a congenital  malforma-
tion; and, when  it occurs, it is mostly as  the result of violent  in-
flammation or burns.   The treatment  consists in dividing the  adhe-
sions with a knife,  guided along a director, so as not to  injure the
eye itself, and keeping  the  edges of the wound  asunder.  If the
cornea be known to be opaque, such an operation is useless.
   As  for adhesions of the  eyelids  to the eyeball, it  is only when
they are loose and  of limited extent, and not situated over the cor-
nea, that the division of them can be of any service.
                DISEASES OF THE  EYE.

  I now proceed  to  consider  diseases of the eye itself;  and first,
inflammation of it, termed ophthalmia, the  most frequent of all its
disorders, and that, indeed, which may likewise be connected with
any other complaint  of the  eye, either  as a cause or an  effect.
It  is  only  of  late  years that  the  various  inflammatory  affec-
tions  of the eye  have been well discriminated;  for ophthalmia
used  to  be  a term  applied  to every inflammation  of the eye, or
parts  appertaining to  it,  whether the eyelids,  the  conjunctiva,
the  sclerotica,   the   iris,   or   the  retina,  were  the  structure
chiefly concerned; and although the epithets mild and severe, dry
and humid,  external  and  internal, were in common use,  the more
valuable distinctions,  deducible from the structure principally  affect-
ed  in different examples, the characteristic  symptoms  of  each  va-
riety, and its most appropriate treatment, were altogether overlook-
ed.   In whatever parts inflammation  occurs, we  know, that  its ef-
fects are always modified by the  structure affected.  Now the eye,
small as it is, contains a great variety of textures, each possessing
both physical and  vital properties peculiar to itself, and consequent- 
56
DISEASES  OF THE  EYE.
 ly exhibiting, under the process of inflammation,  phenomena which
 are  peculiar  to  it.   The modifications  of inflammation, arising
 from differences  of texture, are often beautifully displayed  in the
 eye; and this in so distinct a manner, that its appearances and chan-
 ges  under inflammation are commonly cited by the  pathologists  of
 every school, as presenting,  perhaps,  the very best illustration that
 can  be found of several  most  important points,  relative to the na-
 ture of this interesting process.
   One thing, which I conceive it is very  useful to understand, is,
 that inflammation of the eye  generally commences in one structure,
 to which  it is at first restricted, and beyond which, if it be rightly
 treated, it may not  materially extend.  But if it be neglected, or
 wrongly treated, it soon exceeds its original limits, and perhaps ul-
 timately  invades every part of the organ.   The conjunctiva, the
 sclerotica, the cornea, the iris,  the  crystalline capsule, and the re-
 tina, all severally exhibit a series of the modifications of inflamma-
 tion, dependent upon peculiarity of  texture.   The  mucous tissue
 of the conjunctiva secreting a profuse quantity of  purulent matter,
 as in the  ophthalmia of new-born infants; the fibrous sclerotica, af-
 fected  for months  with  rheumatic inflammation; the transparent
fibre-cartilaginous  cornea becoming  opaque, or  being destroyed,
 layer after layer, by ulceration; the  erectile iris losing all power of
 executing its motions of expansion and contraction; the crystalline
 capsule pouring  out  coagulable lymph from its serous surface, and
 this  lymph forming the medium of morbid  adhesions; the  nervous
 retina, too  deeply seated to  be immediately  observed, but, in a
 few  hours, losing  its inconceivably delicate and specific sensibility,
 are all  so many circumstances illustrating the modifications of in-
 flammatory action,  and the various  consequences of it in different
 textures of the eye.
   Inflammations of  the eye, besides being modified by differences
 of texture, are also much  influenced by peculiarities of constitution,
 constitutional diseases, and certain artificial states of the constitution;
 and  they  are subject  to innumerable  variations,  from the influence
 of those inscrutable  connections  called sympathies.   Scrofula, sy-
 philis,  gout, disorder of the  digestive  organs, and that deranged
 state of the system which is  sometimes  termed mercurialism,  are
 each of them either capable of exciting inflammation in different
 parts of the eye, or,  at least, of communicating to an inflammation
 excited by other causes, such differences in character as shall often
 render the recognition of  the disease  difficult, though  we  may be
 perfectly  familiar with it in its more simple form.
   With respect to the treatment of inflammation of the  eye in gener-
 al, I may observe that, if the disorder be not speedily checked by
 efficient and active  means,  it  will soon  extend  from the texture
 originally attacked  to others,  and that  its continuance  beyond  a
 certain period will permanently impair the delicate structures of the 
            INFLAMMATION OF  THE  CONJUNCTIVA.           57

organ, or even cause a total annihilation of  its functions.   Hence
the necessity of adopting very active treatment; and this, not on
account of any danger to life, or any extraordinary suffering, great
as this may  be, but to  prevent  those changes of structure which
would weaken or destroy the  eyesight.   Hence we are frequently
called upon to take away asmuch blood from the system for an in-
flammatioin  of the eye,  as for  an tnflammation of the pleura  or
lungs, stomach,  or  brain,  or any  other most important internal
organ.   If prompt and vigorous treatment  be not adopted  in  the
early stage of inflammatory  affections  of the eye,  we frequently
find lymph effused,  or opaque  matter  deposited in the transpar-
ent  parts of  the eye;  or the retina more or  less  impaired  in tex-
ture and sensibility; the  pupil rendered  irregular, the motions of
the  iris  prevented by  adhesions;  or the complaint  degenerated
into a chronic form, sometimes difficult of cure, and always  lessen-
ing  the chance of such a recovery as leaves behind it no defect or
weakness of the eye, either with  reference to its moveable, its trans-
parent, or its  nervous textures.
   External inflammation of the eye may be seated in the conjunc-
tiva only or in the sclerotica and cornea.   Simple inflammation of
the  conjunctiva is a much less serious complaint than that of  the
sclerotica.   Yet, specific inflammations  of the conjunctiva are  ex-
ceedingly urgent  cases,  as, for  instance,  violent purulent and gon-
orrhoea! ophthalmies,  which, if unsuccessfully treated, soon  involve
the  organ in incurable mischief.  In sclerotic inflammation, the  im-
plication of the cornea, and the ready transition of the inflammation
to the iris, always expose the organ to considerable danger.
   From these preliminary romarks, I proceed to the consideration
of the chief varieties of ophthalmy, beginning with—
            INFLAMMATION OF THE CONJUNCTIVA,

   Divided into the following kinds:—
   1.  Simple or catarrhal.
   2.  Purulent, or Egyptian.
   3.  Leucorrhoeal, or the ophthalmy of new-born infants.
   4.  (ionorrhoeal.
   5.  Scrofulous.
   1.  Simple  inflammation of  the  conjunctiva.—Catarrhal  oph-
thalmy, as it is often called, generally commences with stiffness and
smarting of the  eyelids, or  a sensation as  if sand had  got  under
them, an increased  secretion from the lachrymal gland, giving a wa-
tery appearance to  the eye, with some degree of redness and unea-
siness upon exposure of the organ to the light.  When fully devel-
oped, the disease is characterised by considerable  redness, and the
 ncreased lachrymal discharge is exchanged for one of a thin  whit- 
58
DISEASES  OF THE EYE.
ish mucus; but the pain is generally slight, and now there is no in-
tolerance of light.  The redness is superficial, and the tint a bright
scarlet, forming a striking contrast to the rose or pink color which be-
longs to inflammation seated in the sclerotica.  The distended vessels
form a network, and the redness is in patches; though, in the fullest
development of the  affection, the whole surface  of the conjunctiva
becomes of a bright red, the redness first showing  itself at the cir-
cumference of the  eyeball, and gradually advancing towards the
cornea.  In severe cases, small  ecchymoses, or effusions of blood,
may be noticed in  the conjunctiva;  and sometimes  little vesicles,
filled  with a  serous fluid, arise upon it, near the margin  of the
cornea.
   The conjunctiva is seldom considerably swollen, and never in the
degree exemplified in what is termed chemosis, or that  remarkable
elevation of the conjunctiva,  which  is sometimes caused in other
ophthalmies by effusion of lymph under it.   There is, however, a
certain quantity of serum  poured out under it, whereby it is some-
what raised up from the sclerotica.
   As soon as the lachrymal discharge, observed in the very com-
mencement, stops, its place is supplied by an increased secretion of
mucus, which is at first thin, but becomes thicker, as the inflamed
conjunctiva goes through  certain stages, assuming a whitish  or yel-
lowish appearance,  and even that of pus.   It is this  altered secre-
tion which, drying  on the eye-lashes in the night-time, makes the
eyelids adhere together, so that  the patient has a  difficulty in open-
ing them in the morning.
   In  every well-marked case of catarrhal ophthalmy,  the  eyelids
participate in the affection; and whenever the attack is severe, other
mucous membranes suffer.  Hence pain and sense of weight about
the frontal sinuses and antrum, disordered stomach,  foul tongue, chills,
succeeded by heat, and other febrile complaints.
   Simple inflammation of the conjunctiva is distinguished from com-
mon inflammation of the external tunics by its catarrhal origin; the
diurnal remission and nocturnal exacerbation of the symptoms;  the
absence of pain and of intolerance  of light, even when there  is
great  general  redness;  the bright scarlet  color of  the  membrane;
the distended state,  and areolar arrangement of its vessels; and the
altered mucous secretion from  the lining of the eyelids.   From pu-
rulent ophthalmy it is distinguished by its milder nature;  its indispo-
sition to  do mischief to the cornea,  or the deeper textures of the
eye; its not being infectious or contagious; its having no tendency
to cause  chemosis; and its freedom from all  the severe sufferings
which attend bad forms of  purulent ophthalmia.
   The origin of this complaint is generally ascribed to atmospheric
causes—exposure to draughts of air or cold winds—sudden changes
from heat to cold.   Frequently it  prevails as an  epidemic  in cer-
tain towns and districts, owing  to  particular states of the air, not 
INFLAMMATION
OF  THE  CONJUNCTIVA.
59
precisely  ascertained;  or  shows itself extensively in  schools.
For its relief, mild antiphlogistic treatment  will  generally suffice;
and it  is not necessary to reduce  the  patient so  much as  in some
other inflammatory affections of the eye; unless  the patient be of a
full habit, or both eyes be severely attacked.   We need  not there-
fore always have recourse to venesection.   In ordinary cases,  cup-
ping and leeches will answer the purpose.  The  bowels, however,
should be freely  opened; and if the tongue be foul, an emetic ought
to follow  the loss of  blood.   Saline and  sudorific medicines, as a
solution of the sulphate of magnesia, with a proportion of tartarised
antimony  in it, may then be given repeatedly, and the feet  put into
warm  water at night.  In a  case of severity, we might, after de-
pletion, put the patent, in the evening,  into  a  warm  bath,  and, di-
rectly  he is  taken out of it, give him a full dose of the pulv. ipecac.
comp.
   As  local applications, we may foment the eye with a decoction
of poppy-heads;  but  afterwards,  when  the inflammation  is on  the
wane,  astringent  lotions, containing three or four grains of the ni-
trate of silver or sulphate of copper, in § iv. of distilled water,  will
be beneficial.   These, with  blisters on the  nape of the neck, or
behind the ear, will generally soon complete the cure: if not,  the
remains of the disorder may be got rid  of by  introducing into  the
eye, once a  day, a drop of the vinum  opii, or  of the  liq. plumbi
acetatis.  To prevent the agglutination of the  eyelids in  the night,
their edges may be smeared at bedtime with spermaceti ointment.
   2.  Purulent or Egyptian  ophthalmy, reputed  to be contagious,
is one of the most violent forms of ophthalmia.   The first stage,
that in which no  pus  is secreted, never surpasses thirty-six hours,
and is often of shorter duration.   At the end of this  time, purulent
matter is always found on some portion of the conjunctiva.  Fre-
quently the patient makes no complaint, till he finds that  his eyelids
adhere together in the morning, or till  the sensation of some extra-
neous  substance in the eye becomes distressing.   In  some cases,  a
sudden attack of darting pain in the eyeball or forehead  is  the first
thing experienced; while, on other occasions, the increased vascu-
larity of the conjunctiva  first excites notice.   The right eye is more
frequently attacked than the left.   It is also in  general  more  se-
verely affected, and the sight of it oftener lost.   In some  instances,
only one eye suffers,  but more commonly both;  although there is
often an interval of several days before the second becomes inflam-
ed.   A considerable  itching is first felt in  the  evening, or a sensa-
tion as if there were dust in the eye, which becomes watery.  This
is succeeded by a sticking  together  and stiffness  of the eyelids in
the morning, which parts appear more swelled than natural.   Their
internal surface is inflamed, tumid, and highly vascular; and the  ca-
runcula lychrymalis enlarged and reddened.   Generally, in about
twenty-four or thirty-six hours, the discharge from each eyelid is al- 
60
DISEASES OF THE EYE.
ready considerable.   It is at first thin, but soon becomes viscid and
opaque, and lodges particularly about the internal anglq.   There is
also a frequent gush of tears, an epiphora, especially \yhen  the eye
is exposed to a current of air.  The  patient always complains of a
sensation  as if the eye were  full of sand, but seems to experience,
comparatively speaking, little uneasiness  from the light.
  .In the second stage, the discharge  becomes  truly purulent, and,
in many cases, so abundant,  that, on the  patient  opening his eyes,
the matter instantly flows over the cheek, irritating  and excoriating
it.   The  quantity of discharge sometimes amounts to several ounces
in the day.   The whole texture  of the conjunctiva may be seen to
be swollen and thickened; its vascularity is increased;  and its color
an intensely bright  red.   Its mucous  surfacex  is rendered  villous,
pulpy, and granular, like  the villous surface of the foetal stomach,
and  from  the secreting surface, thus  produced,  the puriform  dis-
charge flows.   If not checked by effectual treatment, this species
of ophthalmy soon  attacks the layer of the conjunctiva, extended
over the cornea, thickening it, and rendering it more or less opaque.
By these  changes vision is much diminished,  and  very frequently
the  opacity  and consequent diminution  of vision continue  after
all the acute symptoms have  ceased.   But the change in  the cor-
nea  is not confined to this affection of the delicate layer of the con-
junctiva covering its surface;  there is  often an interstitial deposition
between its layers, producing a still worse kind  of opacity; and fre-
quently its texture sloughs or ulcerates; the anterior chamber being
opened, and a discharge of the humors, and a prolapsus of the iris,
being the  too frequent consequences.   In  this manner, both  the
function and form of the eye may be destroyed.
   In some cases, the inflammatory process is still more severe;  ex-
tending even to the internal  textures of the eye, accompanied by a
deep throbbing pain in the eye, coming on in paroxysms;  but,  oc-
casionally, without  any remission till  the cornea gives way.  The
duration of the paroxysms of pain, and their recurrence, are irreg-
ular.  They come on, however, most frequently from  ten to twelve
at night, with an increased secretion from the lachrymal  gland, and
a diminution of purulent discharge.
   Sometimes the swelling of the  conjunctiva is such that the upper
eyelid cannot be raised, and  projects so  enormously that  the lower
eyelid is entirely concealed by it, attended with a great deal of red-
ness of the integuments, extending even to the ^cheeks and fore-
head.
   In many instances, the conjunctiva forms a prominent red  swell-
ing all round the cornea, so as to  give  the appearance of a thick
ridge of flesh encircling the latter membrane, which seems as  if it
were sunk in the eye, with only a very small portion of  its centre dis-
cernible.   This state is technically named chemosis.  If the puru-
lent matter be allowed to lie  some time upon the cornea, it may  ac- 
             INFLAMMATION  OF THE CONJUNCTIVA.          61

quire a thick consistence, and so resemble sloughy membrane that
an inexperienced  surgeon may  suppose the cornea  has  been  de-
stroyed.
   Whether the infection can be propagated from one person to an-
other, through miasmata in the air, arising from the diseased eye, is
a contested point; but that it can  be transmitted by direct applica-
tion  of the  discharge from a  diseased to a sound eye, is  tolerably
certain.   In the Royal Military Asylum, and some other  public es-
tablishments, the matter of  purulent ophthalmia has  occasionally
been applied inadvertently to the eye of another  person, and the
disease been excited.  Yet  it is  curious, that the surgeons of the
French army in  Egypt never suspected its contagious nature.   In
Egypt, and some other countries, in  which it prevails to a great ex-
 tent, the origin of it is usually ascribed  to the combined  effect of
 exposure of the eye to vivid  light and  heat, reflected in  the day-
time from a sandy soil, followed by exposure of the organ to the
 damp,  cold, nocturnal air.
   The constitutional  symptoms are, generally speaking,  influenced
by  the  degree  of pain and  inflammation, and a frequent but soft
pulse, not much  heat of the skin,  the tongue white, not much thirst,
the  appetite good, the bowels torpid.  On the whole, the constitu-
tion suffers less than might be expected.
   The following are some  of the differences of this disease  from
 catarrhal ophthalmia:—1st.  The  peculiar change of structure in the
lining of  the eyelids;  2d. The frequently long continuance of the
complaint; 3d.  The disposition to relapses; 4th. The tendency to
chemosis;  5th.  The  greater  swelling  of the eyelids;  6th.  The
great increased vascularity and redness of the conjunctiva;  7th. The
copious purulent discharge.
   The treatment is strictly antiphlogistic—beginning with bleeding,
which, in young, strong persons, may be carried at once to the ex-
tent of  thirty or forty ounces.   This is absolutely  necessary  if
 chemosis  already exist; leeches should  also be applied  about two
 hours  after venesection,  which  is to  be  repeated according to cir-
 cumstances, the renewal  of inflammatory action, and the state of the
 pulse.  So long as there is a throbbing pain in  the eyeball and orbit,
 the  repetition of bleeding is generally  proper.   Mr. Tyrrell has
 published an account of " a successful plan of arresting the destruc-
 tion of the transparent cornea from acute purulent inflammation."*
 The cornea appears to him to mortify from the strangulation of its
 blood-vessels by the chemosis, or the elevation and  tension of the
 conjunctiva, which covers the sclerotica.   Hence, he was led to
try  what  benefit might  be obtained by  some means, which would
immediately relieve the tension  of the conjunctiva arising  from the
chemosis.   A free division of it, practised with due  regard to the
           * F. Tyrrell, in Med. Chir. Tr. rol. xxi. p. 414.
VOL.  II.                 6 
62
DISEASES  OF THE  EYE.
 course of its principal vessels, was what seemed to  him worthy of
 trial.  The method consists in raising and securing the upper eye-
 lid, and then making free incisions in the sclerotic conjunctiva, and
 the subjacent loaded cellular tissue, without injury to any other tex-
 tures of the  eye.   It  is essential, that the incisions extend  close to
 the margin of the cornea, where  the tension and  pressure are great-
 est, and that the direction of the  wounds correspond to the intervals
 between the insertions of the  recti muscles, so  that  the  principal
 vessels  of the  conjunctiva may not be  injured.   The old plan of
 scarifying the conjunctiva, which  never proved very successful, dif-
 fered from the latter, inasmuch as the incisions were made circular-
 Jy, in the  direction  of  the margin of the  cornea.
   Purgatives are to be given; as a dose of jalap and calomel, fol-
 lowed by  a solution of sulphate of magnesia, containing in each dose
 one fourth of a grain of tartrate  of antimony.    When severe noc-
 turnal pain  is experienced  in the orbit, much benefit has resulted
 from  giving every night two grains  of calomel and one of opium,
 until the mouth is sore, but, under other circumstances, the free use
 of mercury is of no service in purulent ophthalmia.   In the chronic
 stage, when the patient is much debilitated, and the discharge pro-
 fuse, bark and other tonics  are sometimes prescribed.  When the
 cornea is threatened with sloughing, the  same medicine is occasion-
 ally given.
   The local treatment is  fully as important as  the constitutional.
 The first  thing is  completely and frequently, in  the course  of the
 twenty-four  hours,  to  clean away the puriform discharge from the
 eyes.   This is to be done partly with a bit of sponge,  and partly
 with a small syringe, and a  weak alum lotion 5  ss. to half a pint, or
 with a tepid solution of one  grain  of the bichloride of mercury  in
 eight ounces of distilled water.  The best astringent application for
 checking the secretion  is now  generally allowed  to be a  solution of
 the nitrate of silver—from four or six grains to an ounce of distilled
 water, and applied once, or at most twice, in the twenty-four hours.
 Dr. Ridgway even ventured upon  twelve grains to  an ounce of water
 and published a report in favor of this strength; while Mr. Guthrie
 gives the preference to an ointment containing ten grains of it to x i.
 of lard.    In the early stage, relief will also be derived  from ano-
 dyne fomentations, the compound powder of ipecacuanha at night
 and  a mild ointment to prevent adhesion of the  eyelids.
   3.  Purulent opthalmia  of new-born infants is often believed to
 arise from  the eyes coming in contact with leucorrhoeal discharge in
 the birth.   In a great proportion  of cases,  the mother has vaginal
 discharge: exceptions are met with, however; and then the influences
 of draughts of cold  air,  or of exposure of the young eye to vivid
 light, usually fall under suspicion.   Mr. Hugh Carmichael, who has
 commented on thel ittle foundation there is for the opinions  prevailing:
About the  causes of the disease, observes  that the bowels are always 
INFLAMMATION
OF  THE  CONJUNCTIVA.
63
more or less  deranged, and that  this may possibly  operate as  a
cause.*
  In general, the eyelids are first remarked to be glued together abou t
the  third day  after birth, but  sometimes much  later.   On opening
them a drop of thick white matter is discharged, and their inner sur-
face is found  to be swollen and vascular.   If the disease  be  not
checked, the  swelling of the conjunctiva rapidly increases, and  the
inflammation extends from the conjunctiva of the eyelids to  that of
the  eyeball.   The purulent discharge becomes copious, and the skin
of the eyelids assumes a dark red color.  Light is now exceedingly
painful; the child turns its head from it, and resists every attempt to
open the eye.   In this state, the eyes may  continue about a week,
without any affection of their transparent parts, except a slight  ha-
ziness of the cornea.  About the twelfth day, however, suppuration
generally takes place between the layers of the  cornea, its  texture
becomes destroyed,  it ulcerates,  the humors are discharged, and the
iris protrudes.
  If the disease be seen before the cornea  has  suffered, the prog-
nosis is favorable.   If the cornea  has sloughed  or ulcerated,  the
loss of sight is inevitable.
  In the third stage, there is a gradual abatement of all the  symp-
toms;  the redness,  swelling,  and discharge  are diminished;   the
light can be endured; and the eye is more easily examined.
   Treatment.—One  or two  leeches may  be put on the swollen
upper eyelid.   The bleeding from the bites will often seriously  re-
duce an infant, and perhaps,  in ordinary cases, it  is best to be con-
tent with a single leech.   The discharge is to be washed away with
a tepid weak solution  of alum,  or bichloride  of mercury.   The
lids are to be gently  opened, and  the discharge removed   with a
small bit  of sponge.   The  upper  lid has a tendency to remain
everted, but it may usually be replaced, if the swollen conjunctiva
be first  pushed back with a probe into its  right situation.  For
checking the discharge, we may use a solution of the sulphate of
copper, or nitrate of silver: four grains of  the latter,  or six  grains
of the former to an ounce  of water, applying it once or twice a
day, with a large  camel-hair brush, to the whole surface of the  in-
flamed  conjunctiva.   Mr.  Hugh Carmichael prefers,  however,
weaker collyria,  such as one grain  of the  nitrate of silver,  or
two or  three  grains  of alum,  to  the  ounce  of distilled   water.
Neither must we forget to apply the ung. cetacei, to keep the eylids
from  sticking  together in  the night.   If  there be  a  tendency  to
chemosis, one or two leeches are never to  be omitted; the  bowels
are  to be  opened with castor  oil;  and a blister put behind  the
ear.  In  tedious cases, I  usually  give small  doses  of calomel.
The vinum opii is one of the best things for removing the relaxa-
* See Dublin Journ of Med. Science, vol. xv. p. 210. 
64                 DISEASES  OF THE  EYE.

tion of the conjunctiva, left after the  cessation of the discharge.
Sometimes the  disease  has  been successfully  attacked  with the
nitrate of silver  ointment, ten  grains to one ounce of lard.   The
granular state of the conjunctiva generally yields  to astringents, or
the nitrate of silver, or sulphate of copper.
  From  the connection existing  between this  inflammation of the
eye and the state of the bowels, Mr. Hugh Carmichael recommends
giving the  hydrargyrum  cum creta, in grain or half-grain doses,
twice or thrice a day.  In obstinate cases, he also advises  the nurse
to be changed, because her milk may be keeping up the bowel de-
rangement.  He objects  to pap composed  of bread  and  milk, as
likely to become sour.  The bread  should be of the best quality,
and first washed; and the milk be blended with equal, or  two  parts
of water, and sometimes a little  calcined magnesia mixed with it.
Four grains of calomel and  four  drops of tinct. opii, divided into
four or six papers, one of which is taken every night, he commends,
as often the source of much benefit.
  Blisters are mostly disapproved of for infants of tender age; but
if two or three  threads  of worsted  be greased  with  the  blistering
ointment, and placed in close behind the ears, the practice is found
by Mr. Hugh Carmichael to be safe, and productive of great bene-
fit.   When  the  cornea  suppurates, Mr. H. Carmichael  relies  on
leeches, potassio-tartrate of antimony in  doses of one sixth or one
eighth of a grain  three  times  a  day, the application of  blistering
ointment in  the way  described, the  alum wash, or alum  curd.  If
the cornea has sloughed,  he joins  Mr. Saunders in praise  of the ex-
tract of bark, given  to the extent of sixteen or eighteen grains a
day, mixed with pap.
  4.  Gonorrheal ophthalmia in its acute forms is a violent inflamma-
tion of the mucous membrane of the eyeball and lids,  attended with
profuse discharge of matter, closely resembling in all its sensible
properties that which issues  from the inflamed urethra in  clap, and
occurring in some kind of connection with  the latter complaint.
  It  is the most  severe  and  rapidly  destructive inflammation to
which the eye is subject, but fortunately one of the most  rare.  It
is not  the consequence  of the  sudden  suppression of gonorrhoea;
for, in a great majority of examples, the gonorrhoeal discharge is  not
stopped, though, when the affection  of the  eye begins,  the clap
may be on the decline.   As  gonorrhoea is  so  common, and this
species of ophthalmy so rare,  doubts have  often been raised about
its connection with gonorrhoea at  all.  Indeed, the mode  of in-
fection has not  often  been unequivocally traced; but that the dis-
charge from the urethra of one  individual, applied   to the eye of
another person, will bring on  the disease, seems  well  proved  by
facts collected by  Mr. Lawrence; and even that the matter of clap
applied to the patient's own eve,  will bring on this destructive oph' 
      SCROFULOUS  INFLAMMATION OF THE  CONJUNCTIVA.    65

thalmia, is exemplified in the consequence  of the  vulgar custom of
attempting to  cure sore eyes by  washing them with the patient's
own urine; for, if he happen to have gonorrhoea on him, the matter
is then applied directly to the eye, and a destructive purulent ophthal-
mia is the  result, as  related  in  Mr. Lawrence's work " On the
Venereal  Diseases of the  Eye."    The  symptoms are those of
purulent ophthalmy in the severest form, intense redness, extensive
swelling, chemosis,  and profuse  discharge  of thick yellow fluid,
quickly followed  by  ulceration, sloughing, or opacity of cornea.
   The treatment  is not essentially different from that of other severe
purulent ophthalmles.   The boldest antiphlogistic measures are call-
ed for; as  copious venesection, cupping on the temples, numerous
leeches, &c; followed by  blisters, and warm or cold  collyria, ac-
cording to the patient's feelings.   A strong solution of nitrate of
silver, ten grains  to  an ounce, or the strong ointment of the  same,
has sometimes had the effect of checking the disease.
   When the cornea  sloughs, and the patient  is reduced, we may
prescribe  bark.    In gonorrhceal ophthalmy,  the structure of the
palpebral conjunctiva  is not changed; that is,  it does not become
granular; one eye is often  affected; and the disease may begin  on
the sclerotic conjunctiva.   These characters are all different  from
such  as are  usually noticed in ordinary purulent ophthalmy of adults.
      SCROFULOUS INFLAMMATION OF  THE  CONJUNCTIVA.

   The symptoms characterising it are slight redness, great  intole-
rance of light, and pimples or small pustules on the conjunctiva.  It
seldom attacks infants at the breast, but children at some period be-
tween weaning and the eighth year.  At  the commencement of the
disease,  the redness of the  conjunctiva   is  very slight,   and in
patches or clusters of vessels;  but, afterwards, it increases and be-
comes more uniform, and the sclerotica  appears to participate in
the inflammation.  At  the apex of each of the clusters of blood-
vessels,  one or more  minute  pustules  arise; sometimes a single
elevated point,  of  an opaque white color,  near the centre  of the
cornea; and sometimes numerous pustules, scattered over different
parts of the conjunctiva.  In some cases, they are small, and filled
with a thin colorless  fluid, when they are  termed phlyctenule; in
others,  they are larger,  and contain fluid  more like pus.  It is not
known whether there is any  specific difference between the phlyc-
tenular and the pustular cases;  but it has been observed  by Dr.
M'Kenzie, of Glasgow, that the pustular cases are in general at-
tended with less intolerance of light.  The phlyctenular and  pus-
tules may be absorbed, and  then, if situated on the  cornea,  they
leave behind a white opaque  speck—the effect of that effusion of
lymph which surrounds every circumscribed abscess, but which in
                         6* 
66
DISEASES OF THE EYE.
time generally disappears.   Sometimes, however, a vascular speck
is left, which is more difficult of removal.
  Quite as frequently these pimples burst, and are  converted  into
ulcers, sometimes superficial and considerable in extent, more com-
monly deep and funnel-shaped.   If they happen to penetrate  the
cornea, the aqueous humor is discharged,  and a small  piece of the
iris protrudes, and unites  to  the sides of the  aperture, which is
closed by an opaque indelible cicatrix, partially or entirely obstruct-
ing vision; but the cicatrix of a superficial ulcer may leave no per-
manent opacity.
  The excessive intolerance of light, attending  scrofulous ophthal-
my, is one of the most distressing symptoms.   The child  is  quite
unable to open its eyes  in ordinary daylight; and  every attempt to
look up instantaneously brings on a strong spasmodic contraction of
the eyelids.   The pain from the  light  is most severe in the morn-
ing; for, in the afternoon, the intolerance of it  is sometimes so far
lessened that the  eye can be opened.   Notwithstanding  the violent
suffering produced  by light, there is  frequently an insignificant de-
gree of redness, and the cornea often remains perfectly  transparent,
or with merely one minute opaque speck  upon  it,  and a few red
vessels running over the sclerotica.  The intolerance of light is al-
ways  attended with epiphora, a gush  of  tears  following every at-
tempt to open the eye.   Hence, the eyelids and cheeks are some-
times excoriated and swelled.   Occasionally the disease is conjoin-
ed  with iritis; but more frequently with ophthalmia tarsi, and  other
scrofulous complaints.
  In  the treatment, powerful antiphlogistic remedies are less neces-
sary,  than  in  some other  inflammations of the eye.   In  the first
stage, which is  short, we may apply a few leeches, followed  by a
blister behind the ears, or  on  the nape of the neck.   The secre-
tions  of the skin  and alimentary canal are  to be restored; for which
purpose we may  prescribe  the liq. ammon. acetatis, combined with
the vinum antimonii, and a small  quantity of the syrup of  poppies.
Or we may give rhubarb and carbonate of soda, in equal parts, with
or without a little of the hydr. c.  creta.  For the ulcerations on the
cornea, the  solution of nitrate of silver  is the  best  application.
The  eye should be protected from the light with a  green shade, or
by  darkening the room.  If the cornea be opaque, calomel, or the
blue pill, should be given, so as slightly to affect the system.   Af-
ter the first inflammatory stage is over, tonics  are  generally found
beneficial,  especially the  sulphate of quinine, with  light nutritious
diet.
   The best applications to the eye itself are slightly astringent lo-
tions, used tepid; as the decoction  of poppy-heads, with  a small
quantity of spirit of wine in it; or a weak solution of the acetate of
ammonia, or a solution of one grain of the bichloride of mercury in
eight ounces of distilled water.   In France, the collyria  for scro- 
     INFLAMMATION OF  THE EXTERNAL  PROPER  TUNICS.   67

fulous affections of the eye frequently consist of a weak solution of
iodine in distilled water, with a  small  quantity  of  hydriodate of
potash.

      INFLAMMATION  OF THE  EXTERNAL PROPER  TUNICS

Is characterised by a great deal of external redness, pain, and intol-
erance of light, soon followed by increased lachrymal discharge and
febrile disturbance.   The redness begins on the front of the globe,
immediately round the cornea, where it forms a red zone, to which
numerous vessels proceed from the brick of the eyeball.  In inflam-
mation of  the conjunctiva, the redness begins  at the  circumference
of the  organ, its anterior part being at first free from it, and "the
sclerotica  retaining  its natural white appearance : the discharge is
also of a mucous or  puriform kind.
   The  redness is quite different in the two cases : in inflammation
of the sclerotic coat, the vessels seen through the conjunctiva  ex-
hibit a pink color,  or a  lively carmine  appearance,  which forms a
striking contrast to the bright scarlet tint of the vessels in the con-
junctival inflammation.   The vessels of the sclerotic  always follow
the  motion of the eye,  while those of the conjunctiva are capable
of  being moved, independently of the  eye-ball.  The distended
vessels  of the inflamed sclerotica run in  straight lines forwards to
the  edge  of the cornea;  but those of the  inflamed conjunctiva
have no such distribution, as they are reticulated.   However,  the
conjunctiva  soon participates in  the  inflammation of the external
proper coats, and the cornea  looks  dull.  The  eye feels dry and
stiff, with a burning  or aching pain, and feeling of tension, pressure,
or  as if sand were lodged in the eye.   As the disorder increases,
the  pain grows  more  severe,  and extends to  the back of the head
and nearest  temple.   Intolerance  of light is  a strongly-marked
symptom of inflammation of the sclerotica, another feature in which
 it particularly differs from conjunctival inflammation.
   Although  the eye may be at first dry and stiff, the  lachrymal se-
 cretion is soon restored, and even increased, so that whenever the
 eye is opened there  is a considerable effusion of tears.   In unfa-
 vorable  examples,  attended  with  chemosis, the  cornea  first turns
greyish, then white  and cloudy, and lastly yellow, as if pus were
deposited  in its texture.   The yellow matter,  however,  is not  flu-
id;  neither does it make its  way to the surface,  like pus;  but  the
 cornea  ulcerates,  and  the  deposited matter is  removed  by ulcera-
 tion.  A similar deposit may take place in the anterior chamber,
producing what is termed hypopium.   When the whole cornea is
thus affected, the ulceration  may penetrate the anterior chamber at
several points, the  aqueous  humor escape, and the iris either pro-
trude or become adherent to the inflamed cornea.
   The degree of danger will depend  on the state of the cornea: 
68
DISEASES OF THE EYE.
when this is only slightly affected,  there  is no danger; when che-
mosis is present, and the cornea is grey or white, or when a yellow
deposit takes place in  its  texture,  followed by ulceration and  es-
cape of the aqueous humor, sight will be impaired, and perhaps to-
tally lost.
   Before speaking of the treatment, I may as well describe
   Inflammation of the entire eyeball, or ophthalmitis, for the prac-
tice in each of these cases is founded on the same principles. Common
inflammation,  seated both  in  the  external  and  internal  structures
of the eye, when fully developed, is characterised by considerable
pain,  increased external redness, more or less swelling of the organ;
at first dryness of the  eye,  but  afterwards  augmented  secretion
from the  lachrymal  gland; and redness and swelling of  the upper
eyelid.   The  pain is not confined to the  fore part of the eye,  but
is deep-seated, and  extends  to the eyebrow, cheek, temple, and
back  of  the  head.  At first,  the  redness is  inconsiderable, and
chiefly in the vessels of the sclerotic coat;  but the conjunctiva very
quickly participates  in the inflammation, and the distension of its
vessels produces the bright scarlet color, which conceals the  fainter
pink or carmine tint of the sclerotica.  The  conjunctiva then  be-
gins \o swell, and a deposit of coagulating  lymph takes place,  not
only in the texture of that  membrane,  but in the loose cellular  tis-
sue uniting it to the sclerotica.   This red circular projection of the
conjunctiva round the cornea,  giving the latter membrane a sunk
appearance, and even materially concealing it,  receives the name
of chemosis.
  Light is  very offensive, so  that the pupil contracts to exclude it,
and  the  eyelids are spasmodically  closed.   In  a more  advanced
stage, the  color of  the  iris  is altered, its brilliancy  disappears,
and its usual motions in the different degrees of light are  interrupt-
ed; the pupil diminishing  and losing  its  clear black color.   The
cornea becomes more or less opaque, and vision is lost, sometimes
from this cause and the closure of the pupil, sometimes from injury
of the retina, as when the sight is destroyed, though the cornea  and
pupil do not completely obstruct the light,  and frequently from all
these circumstances together.   Sometimes  the  thickened eyelids
protrude, an ectropium of the lower one taking place, and a portion
of the conjunctiva projecting in the form of a piece of red  flesh.
   So violent an affection of  a vascular and sensible organ,  situat-
ed in the  immediate vicinity of the brain, necessarily  produces a
great deal of sympathetic inflammatory fever.   If the disorder be
not checked,  suppuration of the eye occurs, preceded  by  severe
throbbing and rigors; then  no relief is  experienced  till the cornea
bursts, and the matter  is discharged, the vitreous humor  and crys-
talline lens usually passing out at  the same time.   The  eye next
shrinks into the orbit; its form is completely destroyed, and its func-
tions annihilated.  When the disease does not proceed quite  so  far 
     INFLAMMATION  OF THE  EXTERNAL  PROPER  TUNICS.   69

the patient escapes, perhaps, with  opacity of the cornea, a closure
of the pupil, or injury of the retina.
   With respect to the prognosis, if chemosis be formed, the  cor-
nea cloudy,  the color of the iris changed, and the pupil contracted,
the eyesight is in considerable danger.
   The causes of inflammation of the proper coats of the eye may
be wounds;  the irritation of extraneous substances lodged under the
eyelids; exposure of the eye to a draught of cold  air; immoderate
exertion of the  organ,  particularly  in  the  examination  of minute
shining objects, and in hard study by candle-light; and certain states
of the atmosphere.  As predisposing circumstances,  I may mention
a full habit,  or plethora; a  disordered state of the digestive organs;
intemperance; and costiveness.
   Treatment of  Inflammation  of the External  Proper Coats of the
Eye, and of Ophthalmitis, or  General Inflammation of the  Eye-
ball.—1.  The first indication is to remove,  if possible,  the cause;
as, for example,  extraneous substances.   The eye should be exam-
ined in a good light; and, if nothing be discovered on it, the lower
eyelid should be  depressed, and the inferior portion of the globe
brought into view by the patient looking upwards.   If no particle
of extraneous substance can be detected in this way, the  patient
should turn  the eyeball  downwards, and the upper eyelid be raised,
so that the upper portion of the globe may be seen.   In most cases
the extraneous body lodges  in the  concavity of the upper  eyelid,
which must then be everted.   The eyelashes are first to be taken
hold of, and the eyelid drawn downwards; and while steady pressure
is made against its upper part,  by placing a probe across it, its cil-
iary margin is to be carried upwards and backwards.
   When small particles of metal stick  in  the  cornea, they should
be removed with the  point of a cataract needle.
   Next to the removal  of the exciting cause, bleeding is the  chief
means of subduing these forms of  ophthalmic inflammation.  Ven-
esection is to be  practised, and from twenty to forty ounces should
be drawn;  and,  after two  or three  hours,  if the pain return, we
should take away from  twelve to fifteen ounces  more without delay.
The blood may also be taken from the  temple  or nape of the neck,
by cupping, or from the temporal arteries.   The eye is to be guard-
ed from the light with a green shade, or the room darkened.
   Neither must we omit the repeated application of  leeches, which
are to be put on the temple, eyebrow, or just below the inner angle.
We should  also prescribe  purgatives, with  saline antimonial medi-
cines; and, after depletion, have recourse to calomel and blisters.
   With respect to topical  applications, if the case be attended with
violent headache, the decoction of poppy-heads may be used  as a
fomentation   In other instances, we may bathe the  eye, in an eye-
cup filled with tepid water, or with a warm collyrium, containing five
grains of the sulphate of zinc,  or  acetate of lead, dissolved in four 
70
DISEASES OF THE EYE.
or six ounces of rose-water.  In proportion as the irritability of the
eye lessens, the application may be used colder.
  When the acute stage has completely subsided, we may introduce
between the eye and eyelids, once or twice a day, two or three drops
of the  vinous  tincture of opium; but,  while much  tenderness and
aversion to light continue, its use must  be deferred, and depletion
repeated.
  When there is risk of effusion, or opacity, I always give calomel
and opium freely, and keep open a blister.  Two grains of calomel.
with half a grain of opium, four times a day, may be administered,
until the mouth  becomes sore.
  For the cure of any remains of chronic inflammation, astringent
applications, blisters,  the  occasional use of leeches, and the free
exposure of the eye to the  open air and daylight, are generally the
right measures.

          RHEUMATIC  OPHTHALMIA.   SCLEROTITIS.

  There are two remarkable  forms  of inflammation of the eye,
most frequently arising in adults from atmospheric  influences, viz.
—the catarrhal and the rheumatic.  The catarrhal is an affection
of the conjunctiva; the rheumatic, of the albuginea  and sclerotica,
occasionally extending to the iris.   In the catarrhal, the red vessels
give a reticular  appearance; in the rheumatic they are radiated, or
in the form of a zone, and seated under the conjunctiva.  Catarrhal
ophthalmy is an inflammation of a mucous membrane, and attended
with an  increased  secretion from it; rheumatic ophthalmy  attacks
the fibrous membranes  of the eye, and is not accompanied by any
morbid secretion from its surface.   The pain in catarrhal ophthalmy
is like that of sand under the  eyelid, does not extend to the head,
and is felt chiefly in the morning, or when the eyes begin to be mov-
ed.  The pain  in rheumatic ophthalmy is throbbing and deep-seat-
ed, not in the eye chiefly, but round the orbit, and is  severely aggra-
vated from  sunset to sunrise.  In catarrhal ophthalmy, there  is little
intolerance  of light; in sclerotitis, a great deal.
  Rheumatic inflammation is by no means a good name for the com-
plaint, as it is not  connected with a rheumatic constitution;  it is  a
primary affection, and not the  result of  any transfer of rheumatism
from other parts to the eye.   Sclerotitis may be a better term.  At
all events, this inflammation only resembles rheumatism in its excit-
ing causes, its accompanying pain, its exacerbations, and its treat-
ment.
  In sclerotitis, the fasciculi of distended  vessels advance  in radii
towards the edge of the cornea, and sometimes even a little beyond
it.   They are of a bright red  color, and  the degree of inflamma-
tion in the conjunctiva itself is never such as to conceal  them.  In
general, there is no tendency to chemosis, nor  do the evelids  take 
              CATARRHO-RHEUMATIC OPHTHALMIA.           71

 part in the disease; but there is a haziness of the cornea and  pupil,
 attended with a slightly contracted state of the latter opening,  and
 a sluggishness  in the movements of the  iris.   The iris may even
 become a little discolored, and lymph be effused  froniiit;  but a se-
 vere degree  of iritis seldom attends  rheumatic sclerotitis.   Suppu-
 ration and ulceration also  rarely or never follow this affection of the
 eye; but there  is a considerable degree of symptomatic fever, in-
 creasing  with  nocturnal ;paroxysms of pain.   The  digestive organs
 are deranged,  the bowels  confined, and the excretions morbid.
    Treatment.—Blood is  to be taken from the arm, and leeches af-
 terwards applied to the forehead and temples.   Calomel and opium
 are effectual in lessening the severe  pa ;n in and around the orbit.
 Two grains  of  calomel and one of opium may  be given every even-
 ing till the gums are affected, when  the calomel  may  be ^omitted,
 and ten grains of the cot.,pound powder of  ipecacuanha adminis-
 tered  in lieu of it.  The  forehead and temple may be rubbed with
 a mixture of olive oil and  extract of opium, or  with warm laudanum;
 and, in chronic cases, with equal  parts of laudanum and tincture of
 cantharides.   Blisters are likewise to be put behind the ear, or on
 the temple,  or  nape of the  neck.  Great  benefit will  be  derived
 from mild purgatives and the warm foot-bath at night, with sudorifics.
    I believe  that, in rheumatic sclerotitis, the  iris should be kept
 moderately under  the  influence of belladonna, either by smearing
 the moistened extract upon the eyebrow and eyelids every evening at
 bedtime,  or  by infusing  Sj. of the  extract in each ounce of  the
 laudanum used for rubbing the  forehead, eyelid, and temple.
   In chronic cases,  we may  give small doses of sulphate of quinine;
 and, in old mismanaged ones, from three to ten drops of the liquor
 arsenicalis, three times a day.
   Local applications have little effect.  The lunar caustic solution,
 which  is almost a specific  for catarrhal ophthalmy, is decidedly  in-
 jurious in  rheumatic sclerotitis;  but,  when all painful  and febrile
 symptoms are gone, and little more than chronic redness and weak-
 ness of the  eye remains, the vinum opii may be dropped once  or
 twice a day  into the eye.

             CATARRHO-RHEUMATIC OPHTHALMIA

 Affects both the conjunctiva and  the sclerotica.   The feeling of
 roughness, or sand, between the eyelids and eyeball, and the secre-
 tion of a puriform fluid, indicate the participation of the  conjunctiva
 in the disorder;  while the nocturnal accession of racking pain in and
around the orbit marks the affection of the sclerotica.  In this case,
chemosis is by  no means uncommon, and  the eyelids generally ad-
here together in the morning, from the thickened state of the Mei-
bomian secretion.   There  is also considerable  intolerance of light,
with epiphora. 
72
DISEASES OF THE EYE.
   The cornea  frequently ulcerates, or pus is effused between  its
layers, constituting what is termed onyx.  In bad cases, the ulcera-
tion makes its way into the anterior chamber, the  aqueous  humor
escapes,  and  the iris protrudes.   There is also commonly, just  be-
fore this  state of things, an effusion of fibrine in the pupil; the  iris
changes in color, and the pupil is  often obliterated.   The pulse is
generally  quick and sharp, the tongue white, and the nocturnal pain
prevents  sleep.
   Treatment.—1st.  Venesection—from ten to thirty ounces,  and
repeated.
   2d. Leeches to the temple.
   3d. Scarifications are sometimes advised for the chemosis, and
if  practised,  should be  so, in the  way noticed in  the remarks on
purulent  ophthalmy.
   4th. Calomel and opium every night.
   5th. Opiate frictions about an hour before the expected attack of
pain in the orbit.
   6th. Pupil to be kept dilated  with belladonna.
   7th. Blisters behind  the ear.
   8th. Purgatives; a brisk dose of calomel and jalap at first,  and
afterwards mild  laxatives.
   9th. Sudorifics; liq.  ammon.  acet., warm diluent drinks, and the
pediluvium.
   10th.  In the chronic  stage, the  sulphate of quinine and  mineral
acids.
   11th.  Local applications: the solution of from two to four grains
of the nitrate of silver in an ounce of  distilled  water, dropped upon
the conjunctiva once a day, relieves the painful feeling of sand, and
speedily  removes the other symptoms of conjunctivitis.
   The eye is to be bathed three or four times a day with a tepid
solution of the bichloride of mercury  one grain to  eight ounces of
distilled  water.
   The edges of the eyelids are  to be smeared  with the ung. hydr.
nitratis, weakened.  If  onyx take place, it is  not to be  punctured,
as such practice would  be followed  by protrusion of the iris  and
opacity.

                    SCROFULOUS  CORNEITIS

Is a slow disease, occupying weeks  and  months, and  sometimes
years.   The conjunctival covering of the  cornea, and substance
immediately  under it,  are  chiefly affected.    The  redness  of  the
sclerotica is not considerable; the vessels are minute, and  arranged
in a zone round the  cornea.   Not  unfrequently, there is a  reddish
ring at the circumference of the cornea, with red vessels extending
to the centre of this membrane.  In some  cases  the conjunctival
covering  is thickened, and reddened,  so as to  look like  a  piece of 
IRITIS.
73
red cloth, whence the term pannus.   The cornea is more or less
opapue and  rough; sometimes only hazy, sometimes marked with
white streaks or specks, sometimes uniformly white.  Occasionally
its convexity is increased;  the pupil is not unfrtquently dilated, with
a tendency  to amaurosis; there  is not much intolerance of light—&
striking contrast of this form of  scrofulous inflammation of the eye
to what is noticed in the pustular variety.  In a few cases, however,
the patient cannot  endure  the light,  and there  is epiphora.  The
pain is not very severe, and the complaint  soon becomes chronic,
especially after the cornea has  become opaque.   The pulse  is es-
pecially  quick, the patient restless at night, and the skin harsh and
dry.   The  disease is most common  in  subjects about puberty, and
often accompanied by symptoms of struma.
   Treatment.—Leeches are to  be applied and repeated;  but not so
as to weaken the patient.   We  may  also try small doses of tartar-
ised antimony, and then the sulphate  of quinine, and  Dover's pow-
der at bedtime.   Calomel, combined with opium, so as to affect the
mouth, after the  acute symptoms have ceased, has  great effect in
clearing  the cornea.  Colchicum, sarsaparilla, and  elm bark, are
useful as  alteratives in scrofulous corneitis, but not  generally equal
to sulphate  of quinine.
   The local applications are fomentations with poppy decoction,
and the steam of hot water,  with a little  laudanum in it.    Blisters
are productive of great benefit.    The best stimulating applications,
after all acute inflammation is over, are the vinum opii, a collyrium
of  the  nitrate of silver, or  a  weak  solution of iodine in  distilled
water, according to Lugol's formula.   When there is any tendency
to iritis, the pupil is to be  kept  dilated with belladonna.   When the
cornea is very  convex, denoting an unusual accumulation of the
aqueous humor, the discharge of this  fluid is sometimes recommend-
ed, but rarely adopted.

                             IRITIS.

   When we recollect, that the  iris receives its supply of blood by
the two long ciliary arteries, the external and internal, which are but
little connected with the arteries of the  other textures  of the eye,
we may  readily  conceive that  inflammation of  this organ is  likely
sometimes to exist without much  inflammation in other parts of the
eye.   The danger of iritis chiefly depends upon its partaking of the
nature of the adhesive inflammation,  by which the pupil is apt to be-
come, under the least neglect, completely and irremediably obliterat-
ed  by the effusion  of coagulating lymph.  Iritis is, indeed, attend-
ed  with a degree of inflammation in the sclerotic coat, the front lay-
er of the capsule of the crystalline lens, and too often with inflam-
matory action in the choroid coat and  retina; yet the iris is plainly
   VOL.  n.               7 
74
DISEASES  OF THE  EYE.
the focus of diseased action, the affection commencing on its pupil-
lary margin, and other parts becoming subsequently affected.
  Iritis is divided into idiopathic and symptomatic, acute and chronic,
and into several specific varieties.   Some common symptoms, how-
ever,  characterise iritis, from whatever cause it may originate.
  1.  In the early stage we can discern  minute red vessels, running
in radii in the sclerotica to the edge of the cornea, where they form
a red  zone, while the rest of the sclerotica retains nearly its natural
paleness, its vessels  under the  conjunctiva  only  presenting  a pale
pink color, which increases, however, as the iritis makes progress.
The vessels of the conjunctiva in the anterior part of the eye soon
enlarge; and, in violent cases, there is a uniform redness.  Together
with change of color, the iris loses  its natural brilliancy; it becomes
of a dull appearance;  and the beautiful fibrous arrangement, so char-
acteristic  of it in the healthy state, is either confused or entirely
lost.   These changes begin in the pupillary margin.
  2.  Then, another symptom, common to every iritis, is a change
of color in the iris: if naturally blue, it turns greenish; if dark-col-
ored,  it changes to a reddish brown.   This is owing to the deposit
of fibrine in its texture,  and to the effusion of the same plastic sub-
stance upon its surface.   Hence we  frequently notice irregular tu-
bercles, or masses, formed  either at the edge of  the pupil, or upon
the iris itself.
  3.  Another  symptom, noticed  in every  iritis, is a tendency to
contraction, irregularity, and immobility of the pupil.
  4.  We also frequently remark an effusion of fibrine into the pupil
and posterior chamber, and  sometimes into the anterior.   In rheu-
matic iritis, however, fibrine is more sparingly effused than in vene-
real iritis.
  5.  Considerable  intolerance of light, accompanied  by increased
lachrymal discharge, is another effect of iritis in general; but much
greater in rheumatic than syphilitic  iritis.
  6.  In every iritis there is a disposition to the production of adhe-
sions  between the pupillary margin  of the iris and the capsule of the
lens;  and sometimes  between the iris and  cornea, or even between
the posterior part of the iris and the  ciliary  processes.   Such ad-
hesions are usually of a dark color, like that  of the edge of the
uvea.
  7.  Together with these common  effects of iritis, the patient has
dimness of sight, and sometimes total blindness.
   8.  Pain in the eye, the orbit, and  forehead, are likewise invaria-
ble attendants on iritis,  and often subject  to nocturnal exacerba-
tions.
   Notwithstanding what has now been stated, iritis, if combined with
amaurosis, may be accompanied by a dilated pupil.
   Exposure to atmospheric changes, very strong light, syphilitic dis-
ease, scrofula, gout, rheumatism, wounds of the eye, may each be 
                             IRITIS.                           75

a cause of iritis, which  may be acute or chronic.    When  acute,
the inflammation, beginning on the pupillary margin of the iris, quick-
ly extends over its whole surface, and affects the external as well as
internal tunics.   In chronic iritis, the inflammation sometimes  begins
at the ciliary margin of the iris, whence it may be slowly propagated
to other internal textures.   Cnronic iritis, however, sometimes pro-
duces effusion of fibrine, and adhesion of the edge of the iris to  the
capsule of the lens,  without any perceptible inflammation of other
textures of the  eye.   Between this slowly creeping chronic iritis,
and the most acute form of it, we meet with numerous other cases,
in which every gradation of the inflammatory process is exhibited.
   The constitutional disturbance  is  different  in  different  cases.
Acute iritis is generally  attended with headach,  restlessness,  a  full
and strong pulse, white tongue, thirst, loss of appetite, and costive-
ness.  At the same time, it must be confessed, that, in some  cases,
which  would be regarded as acute, such symptoms prevail only in a
slight degree.
   The prognosis is favorable, when the affection is  recent and con-
fined to the iris, without too close a contraction of the  pupil, or  or-
ganisation of the effused fibrine; or extension of the  inflammation
to the  retina, and other textures behind the iris.
   Syphilitic iritis is frequently,  but  not invariably, accompanied
with effusions of fibrine,  in the form of  tubercles  of a reddish or
yellowish brown color; it is also  characterised by a reddish  brown
discoloration of the inner circle of the iris, the remarkable noctur-
nal exacerbations  of pain*,  the previous occurrence of syphilis,
and, in most instances, the  concomitant existence of other syphilitic
symptoms.   There is an angular disfigurement of the pupil, which,
according  to  Beer,  is usually drawn  towards the root of the nose;
but, according to Mr. Guthrie, not more frequently  in this direction
than others.   The form and situation of the pupil seem to Mr. Law-
rence to depend upon the effusions of fibrine.    With regard to  the
opinion, that mercury is the cause of iritis, Mr.  Lawrence's  obser-
vations are strongly against  its correctness; in nine cases, related in
his " Treatise on Venereal Diseases of  the Eye," iritis  came  on
where no mercury  had been taken previously to  its appearance.  In
some cases of syphilis, treated  by Rose  and Thompson, without
mercury,  iritis also occurred.
   In idiopathic  iritis, there is either no  distinct deposit upon  the
iris, or it presents itself as a bright yellow elevation from the tex-
ture of the part, increasing to a certain size,  and then  breaking, so
as to allow the escape of a yellow matter, which sinks to the bot-
tom of the anterior chamber.  Such yellow little abscesses are not
observed in syphilitic iritis.
   In arthritic iritis,  or that connected  with  a  gouty  constitution,
* See Lawrence's Treatise on the Diseases of the Eye, p. 317. 
76
DISEASES OF THE EYE.
fibrine is effused from the margin of the pupil, but not deposited  in
a distinct form, and the adhesions are generally white.   Both in the
idiopathic and arthritic iritis, the pupil is  contracted; but generally
retains its circular figure and central position in the iris.   In  gouty
and rheumatic iritis,  a white zone is distinguishable between the red
one and the margin of the cornea; but  frequently it is  incomplete,
being only noticed on each side of the  boundaries of the cornea.
   In the treatment of iritis, there are three principal indications :—
   1.  That of putting a stop to the inflammation.
   2.  That of preventing the effusion of fibrine,  and promoting its
absorption, if it has been already poured out.
   3.  That of preventing the contraction of the pupil,  and the for-
mation of adhesions between the margin of the iris and  the capsule
of the lens.
   The first indication, or that of arresting the inflammation, is ac-
complished  by antiphlogistic measures; bleeding, saline aperients,
and tartarised antimony.   If the  inflammation is not  checked,  it
will soon extend to the choroid coat and  retina,  and sight be en-
dangered.  We should have recourse, therefore,  to venesection,  or
cupping from the temple,  or nape of the neck.   Sometimes bleed-
ing and the exhibition of sulphate of magnesia, and tartrate of anti-
mony,  with other antiphlogistic means, will accomplish  the cure of
iritis, if duly  followed up; but more  frequently additional plans are
requisite.   Antiphlogistic treatment relieves the  congestion of the
blood in  the eye, lessens the redness, and diminishes the fever;
but it does not always succeed in preventing the effusion of fibrine,
or in bringing about the absorption of what has been poured out.
   This makes it  necessary to consider how the  second indication,
or that of preventing  the effusion of  fibrine, and  promoting its ab-
sorption when deposited, is to be fulfilled.   Experience proves that
the grand remedy for this purpose is  mercury,  employed quickly
and freely, so as to  affect the system.   It must  he used immedi-
ately after bleeding and other means of depletion  have been prac-
tised.  The  effect of it is so to change  this action of the vessels of
the iris, that  they lose their  disposition to effuse  plastic substance;
and that  which  has  been already effused  becomes absorbed ;  the
natural color of the iris is restored, the cornea becomes clear again,
the red zone round it fades  away, and  the power of vision returns.
All this  improvement is rapidly effected when the system is expe-
ditiously put  under the influence of mercury; and  here it  is  advis-
able to let that influence be  stronger, than what  is usually deemed
necessary in  other cases of  ordinary disease.   Two grains of calo-
mel with one third of  a grain of opium, are to be given every  four
or six hours.  In cases of long standing,  it is necessary sometimes
to keep  the patient under the influence of mercury several weeks.
   The third indication, or that of keeping the pupil dilated, requires
the application of belladonna. Other narcotics will produce the same 
CHOROIDITIS  AMD  RETINITIS.
77
effect, particularly stramonium  and hyoscyamus; but belladonna is
most effectual.   One scruple of the extract should be dissolved in
Sj. of distilled  water,  and filtrated.   This preparation is to  be
dropped, once or twice a day, into the eye.  But,  if the inflamma-
tion be acute, it is better to smear  the upper eyelid, forehead, and
eyebrow with the extract  itself, a  little moistened.   The other,
however, is the  most prompt method, if the  inflamed  state of  the
eye will bear it, which is not always  the case.   This use of bella-
donna is very important; not only as  tending to  prevent the closure
of the pupil, but as keeping its edges away from the capsule of  the
lens,  and even making the  iris so withdraw itself from the lens that,
if adhesions be  already formed, and  the fibrine  soft, they will give
way,  and the pupil still recover  its natural size and  mobility.   This
beneficial change is materially promoted by the  simultaneous use of
mercury.   While the iris is  highly  inflamed, and  the disease  not
checked, belladonna will not dilate the  pupil; yet,  if applied only
to the skin,  and not to the eye itself, Mr. Lawrence is of opinion that
it will do no harm, and perhaps  may even  prevent  further  contrac-
tion of that opening.   Other local applications are of secondary
importance; poppy fomentations  generally  give most  relief,  but
cold applications may be used, if preferred.  Blisters are not advis-
able until the disease becomes chronic; or, not  until bleeding  has
been  freely practised, and  mercury exhibited.
   When there is severe nocturnal pain about the orbit, the  forehead
and temple should be rubbed with mercurial ointment combined with
opium, in the proportion of four grains  of the latter to one scruple
of the former.
   In  arthritic or gouty iritis, mercury is less necessary than in  the
idiopathic  and syphilitic forms  of  the complaint.   Colchicum and
magnesia, and, iii the chronic stage, blisters, carbonate of iron, and
quinine, are means  on which some practitioners place their chief de-
pendence.   We should not imbibe the notion,  that syphilitic iritis
absolutely  cannot be cured without mercury.   Sometimes it may be
cured by antiphlogistic treatment alone; and Mr. Hugh Carmichael,
of Dublin, has  published a series of well-marked  examples of  sy-
philitic iritis,  which were  cured by giving 3j.  doses of turpentine
in the almond emulsion, three  times  a day.  Yet he only resorted
to this practice  when mercury was inadmissible, in consequence of
its injurious effect on the health.

                 CHOROIDITIS   AND RETINITIS.

   The internal inflammations  of the  eye  may sometimes  arise
in one texture, and, at other times, in another; in one case, the  re-
tina may be first affected;  in  another, the choroid  coat; and, in a
third, the iris.   From these individual  textures, the inflammation
may afterwards  extend  to every part  of the eye. 
78
DISEASES OF THE EYE.
   Retinitis is  occasionally excited by long-continued immoderate
exertion of the sight in the examination of minute microscopical ob-
jects, under a strong,  and, perhaps, a reflected light.   Such cases,
however, are  generally preceded by determination of blood  to the
head, or the eye.   The same consequence may follow the effect of
vivid flashes  of lightning, or the sudden  exposure of the eyes of
persons to the light, who have long been confined in dark dungeons.
Chronic retinitis is often regarded as weakness of sight, character-
ised by a morbid  sensibility to light, and slight obscurity of vision,
followed,  after a time, by a gradual  contraction of the  pupil, im-
mobility of the iris, and amaurosis.
   The treatment of acute retinitis consists in keeping  the eyes per-
fectly at rest, with the benefit  of darkness, abstinence, and  active
depletion, followed by the quick introduction of mercury  into the
system, belladonna being also applied, as in iritis.  The treatment,
indeed, is essentially the same in both cases.
   Having now finished the consideration of  the principal inflamma-
tions of the eye, I proceed to notice some other affections  which
are consequences of an inflammatory  process in that organ.

                          GLAUCOMA

Is so called from the greenish color reflected from the pupil, the iris
becoming  of a dull leaden or dirty green color, the pupil dilated, the
eye painful, its vessels  distended,  and vision generally  destroyed.
In the early stage, the green reflection seems as if it came from the
very bottom of the eye; but, as the disease advances, the apparent
opacity, which is always of  a  greenish color, and often sea-green,
looks as if it were situated in the centre of the vitreous humor, and
at last  appears to  be  immediately behind the lens.   The opacity
and greeu reflection are not the result of  any change in the crystal-
line lens, but are more deeply seated.  The change cannot be seen
when the eye is inspected laterally, but  only when we look directly
towards the bottom of the eye.
   Scarpa ascribes the glaucomatous state  of the eye to inflammation
and thickening of  the retina;  Beer  to similar alterations of  the vi-
treous humor;  and other surgeous to morbid changes  in both these
textures.   Dr.  M'Kenzie,  in  dissecting  some glaucomatous eyes,
found the choroid  coat, and especially the portion of it in contact
with the retina, of a light brown  color, without any  appearance of
pigmentum nigrum.   The vitreous humor was  in a fluid state, per-
fectly colorless, or slightly yellow,  without  any trace of hyaloid
membrane.   The lens was of a yellow or  amber color,  firm and
transparent.   In  the  retina, no trace of  the  foramen centrale and
limbus luteus was  distinguishable.  No other change was noticed in
the retina; for it was not thickened, nor changed  in  color;  neither 
ONYX,  OR  ABSCESS  OF  THE  CORNEA.
79
was the vitreous humor thickened, or opaque, but perfectly fluid and
transparent.
  Glaucoma is always attended with a limited and  sluggish motion
of the  pupil  and other amaurotic  symptoms.   Ultimately, indeed,
the pupil  is greatly  dilated, and  the  retina becomes insensible to
light.  The  loss of sight, however, is  generally gradual;  and the
want of pigmentum nigrum has been suspected  to be capable of af-
fording some explanation of the weakness of sight, which accompa-
nies  the early stages.  This, however,  may not seem satisfactory
to every pathologist;  nor are we sure, that a deficiency of pigmen-
tum  nigrum is an essential occurrence in every  glaucoma.
   Inflammation, leading  to a destruction of the hyaloid membrane,
may perhaps be set down as the proximate cause of glaucoma.  The
disease is much more common  in old than young subjects, and  is
occasionally believed to come on chiefly in consequence of slow
inflammation of the interior textures of the eye in gouty constitutions.
Surgeons must be careful not to mistake glaucoma for cataract; the
mere color of the eye is sufficient to prove that, at all events, the
case is not one of simple lenticular cataract, for opacity of the lens
alone is never green.  Also, when the pupil  is dilated  Avith bella-
donna, the green appearance seems to be  further behind the pupil,
and  uniform, not streaked,  nor spotted like a cataract.
   When glaucoma has commenced in one eye, we  generally find it
take place also in the other, the disease being often  seen in different
stages in the two eyes.
   Complete glaucoma  may  be set down  as absolutely incurable,
though it is possible that, in the early stage of the disorder, its pro-
gress may  be arrested, and even vision improved.   I should say,
however,  that the prognosis is always peculiarly unfavorable.   Mild
antiphlogistic treatment, with calomel and  opium, may  be  tried, or
iodine given; but the prospect of benefit is very slight indeed.
   Instead of mercury,  Dr.  M'Kenzie, of Glasgow, suggests the
trial of carbonate, or sesqui-oxide, of iron and sulphate of quinine,
directly after depletion, but I know of no fact in support of the prac-
tice.  Dilatation of  the pupil  with the aqueous solution of bella-
donna will sometimes temporarily  improve the  sight.

              ONYX,  OR ABSCESS OF THE CORNEA,

Signifies a collection of matter between its lamellae, and so  called
from its being of a semilunar shape, like the white mark at  the root
of one of the finger-nails.   It is generally  situated at the lower edge
of the cornea, and, even when more extensive, may be readily dis-
tinguished  from a collection of matter in  the anterior  chamber, called
hypopium, by its form and  situation remaining unchanged, whatever
may be the position of the patient's head.
   The treatment consists  chiefly in  the  employment of remedies 
80
DISEASES OF THE EYE.
called for by the kind of ophthalmy, of which the onyx is an effect.
As the general rule, it is the best practice not  to open any collec-
tions of matter in the texture of the cornea, as we thus  rather  in-
crease, than lessen, the risk of opacity of that membrane, and pro-
lapsus of  the iris.  When,  however,  the onyx has a tendency to
spread over the cornea without bursting,  it  becomes necessary to
make an  opening with a cataract knife.

                          HYPOPIUM

Is a collection of matter in the chambers of the aqueous humor, es-
pecially the anterior.   The matter is always first noticed at the
bottom of that chamber; and it may  increase gradually, till  it not
only covers the pupil, but fills  the  chamber, and  even  the  pupil.
Sometimes it shifts  its position with every  motion of the head; and,
in other examples, its thick glutinous properties fix  it  in  one place.
If the case be neglected, the prominence   of the cornea increases,
and, at last, after most  agonising pain, that  membrane gives way:
the suffering now ceases, and the iris falls  forwards, protrudes, and
becomes  adherent to the cornea.
   In the  treatment,  the  principal indication is to lessen the inflam-
mation, from which  the hypopium has originated, whether  of the cor-
nea or the iris;  for,  if we succeed in doing this promptly, and then
give mercury, absorption will often proceed so quickly in the ante-
rior chamber, that the matter will soon be removed.   The best gen-
eral rule is to abstain from making an opening; for, in fact, the mat-
ter is a viscid kind of lymph, which will not  flow out if a puncture
be made.
   If the  eyeball were to suppurate extensively, things would be dif-
ferent, and then an opening for  the discharge of the abscess would
unquestionably be required.
   Ulcers of the cornea are frequently the  consequence of the rup-
ture of an onyx or small abscess.  In purulent ophthalmy, however,
the ulceration generally begins externally,  and penetrates more and
more deeply, until it reaches  into the anterior  chamber.   Some-
times ulcers of the  cornea  are produced  by the irritation  of ex-
traneous  substances on  the eye, as  quicklime, or  pieces of glass.
The ulcer is of a pale ash color; its  edges high and  irregular; its
margin surrounded by a slight  halo of lymph, or a  cloudy appear-
ance of the cornea; it  gives acute pain, discharges a thin lymph,
and is disposed to spread.   To the deposit  of lymph around the
sore, a fasciculus of vessels  proceeds from  the sclerotic coniunc-
tiva.                                                      J
   When  the ulceration extends  superficially, the  transparency of
the cornea may be destroyed;  and when it penetrates  the anterior
chamber,  the aqueous humor escapes, and a prolapsus of the iris
takes place.  If the opening be large, even the vitreous humor and 
          OPACITIES AND SPECKS  OF THE CORNEA.         81

lens may be discharged, and  the  eye destroyed.  Then, if less
mischief occur,  the cicatrix  frequently produces  indelible opacity
of the cornea, and more or less injury of vision.
   Treatment.—Our first endeavor should be  to stop the ulcerative
process by means calculated  to lessen the inflammation,  which is
the cause of it.  Local  bleeding is  proper, so long as there is an
appearance of active inflammation, and much pain  is felt in  the eye.
The  bowels are to  be kept open, and  opium administered.   In
strumous cases, we may give the sulphate of quinine, and wash the
eye with a collyrium containing iodine, according to the formula of
Lugol.   In  the chronic superficial ulcer, we may  prescribe calo-
mel.   In almost all cases,  counter-irritation is useful.  When  the
ulcer is  kept  from healing by the irritation of the motion of the
eyelids, and it protracts the inflamed state of the eye, lunar caus-
tic is the grand means of relief.

          OPACITIES  AND SPECKS OF  THE  CORNEA

Receive different names  according to their  degree and  mode of
formation.   The slightest degree of opacity  is termed  nebula, in
which the cornea presents  a  diffused  cloudiness,  a hazy or milky
appearance, that has no distinct  boundary, but  is gradually lost in
the surrounding transparent portion of that membrane.   It  is often
accompanied by an enlarged  and reddened state of the  vessels of
the conjunctiva, some ramifications of which extend into the deli-
cate layer of this membrane,  spread over the cornea.
   Opacities of a more circumscribed  and complete kind are exem-
plified in Jllbugo and Lcucoma, which consist of a deep extravasa-
tion of dense lymph  in the substance of the cornea.  They are of
a clear white or pearl color, and only differ in one  respect;  namely,
that the albugo is the consequence of  some description of ophthal-
my, or of an abscess, or ulceration of the cornea, while the leucoma
is the opaque  speck or mark occasioned by a wound of that texture.
For some time  after  the completion  of the healing process, the
opacity continues to diminish; but this improvement can only take
place in a certain degree, and an indelible speck  will yet remain,
though considerably smaller than the original wound which was tho
cause of it.
   Numerous red  vessels are  sometimes observed running into an
albugo from  the conjunctiva; and, when this is the case, the opacity
is apt to spread, and  is  somewhat raised above  the level of the
cornea, the delicate layer of the conjunctiva spread over this mem-
brane being  much  thickened.  This variety of albugo is occasion-
ally seen in scrofulous adults, and  sometimes  in children.
   The remedies, calculated to do  good to specks  of the cornea, in
their early stage, are those  which have the effect  of removing  the
inflammation that has given rise to them.   At the  same time,  there 
82
DISEASES OF THE EYE.
 are both general and local means  peculiarly adapted for hastening
 the absorption of opaque deposits in the cornea; such are mercury
 and  iodine.  We have likewise various applications for  quickening
 the action of the absorbents in the removal of specks, if employed
 at the proper time.   If we commence their use  too soon,  that  is,
 before the cause of the opacity is  removed, we shall do  more harm
 than good.  For instance, if  in an albugo, arising from scrofulous
 corneitis, and still  attended  by considerable  vascularity, we were
 directly to attack the opacity of the cornea with stimulating pow-
 ders and  strong solutions of  nitrate of silver, oxymuriate  of mer-
 cury, or iodine,  we should not only fail in accomplishing the object
 in view,  but create  a great risk  of rendering the patient  totally
 blind.   But, if we  begin with attacking the strumous inflammation,
 which still lingers in the eye, and that chiefly with constitutional
 remedies, we  shall  not only disperse the redness, but often find the
 cornea begin to get clearer from day to day, and the eyesight to  be
 proportionally improved.
   The best local means for dispersing opacities of the cornea are,
 a solution of the nitrate of silver,  from two to  five  grains, in  an
 ounce of  distilled water;  a solution of one  or two grains of oxy-
 muriate of mercury in an  ounce of distilled water; the vinum opii;
 the ung.  hydr. nitratis;  or a finely  levigated powder,  consisting of
 3|. of red precipitate and one ounce  of white sugar.    The latter
 is generally blown on the speck through a quill.   The useful effect
 of iodine collyria must also not be forgotten.   The vascular forms
 of albugo sometimes require  the trunks of the  vessels  distributed
 to them to be  divided, and mercury or iodine to be exhibited.

                          STAPHYLOMA

 Is a  term applied to various protrusions or  projections on the front
 of the eye, in  consequence of their fancied resemblance  to a grape,
 staphyle being the Greek word for that fruit.  Thus, a  protrusion
 of a portion of the  iris through  an ulcer, or wound of the cornea,
 used to be called staphyloma  racemosum, but  now more properly
prolapsus of the iris.   At the present  time, the term staphyloma is
 usually restricted  to protuberances of the  cornea and  sclerotica.
 Staphylomatous  affections of the sclerotica, however, are so rare,
 in comparison with those of the cornea, that  it is only the  latter
 which need detain us.   When the cornea becomes staphylomatous,
 it looses  its natural  transparency, rises above  its  proper level, and
 even projects between the eyelids,  in the form of a whitish, pearl-
 colored, or bluish tumor, attended, when the whole cornea is affect-
 ed, with  loss of sight.   To this grievance are added, in bad cases,
 all the evils which  unavoidably result from  the projection  of the
 cornea:  inability of closing the eyelids; exposure of  the eyeball to
 the air and extraneous matter  suspended in it;  irritation  and inflam- 
STAPHYLOMA.
83
 mation from this cause and the friction of the eyelashes;  and sore-
 ness and  excoriation of  the lower eyelid and cheek from the con-
 stant stillicidium lachrymarum.  Even the other eye is often sympa-
 thetically affected, becoming tender, and sometimes truly inflamed.
   Staphyloma  of  the cornea is either partial  or total.   Although
 the most evident symptoms are opacity and projection of the cornea,
 a common effect of the  disease  is adhesion  of the iris to the diseas-
 ed cornea and consequently a diminution or total obliteration of the
 anterior chamber.
   Where a partial staphyloma neither covers nor involves the pu-
 pil, the patient may be able to see objects placed above him  or on
 a level with his  eye; but he is generally affected with epiphora  and
 painful sensibility of the organ.   In more unfortunate cases, all the
 margin of the pupil is adherent to the opaque and projecting portion
 of the cornea; and it is only by the formation of a lateral artificial
 pupil, that any degree of vision can be recovered.
   Partial staphyloma is  sometimes confounded with leucoma;  but
 it is to be recollected, that in general the iris is firmly adherent to
 the whole extent of a partial staphyloma,  but either quite uncon-
 nected with a leucoma,  or connected to it by a  mere point.  In
 partial staphyloma, the whole cornea inclines to a conical form,  the
 apex of which is the centre of the staphyloma;  whereas, in leucoma,
 the general  spherical form  of the cornea remains unaltered.
   If either from closure  of the pupil, or from the partial staphyloma
 being situated over it, no vision  exits, we should try to  lessen  the
 staphyloma  itself,  and then consider whether,  by an operation for
 artificial pupil, the  eyesight can be  restored.
   Now, the safest plan of  reducing a partial staphyloma is to apply
 to its apex the muriate of antimony with a camel-hair pencil, while
 the eyelids are kept  widely separated.  Then, before the eye is
 shut,  the  surface of the  staphyloma should be washed with a large
 camel-hair pencil dipped in tepid water or  milk.   The caustic is
 not to be repeated till the slough has come away, and the inflamma-
 tion, caused by the former  application, subsided.
  In  one  form of  total staphyloma, the  tumor is spherical;  in  the
 other, it has the shape of a blunt cone.
  As there  is no possibility of restoring sight to a  patient afflicted
 with total staphyloma, even in cases where the lens, vitreous  humor,
 and retina are sound, the only thing we can usefully do is to lessen
 the protuberance of the  cornea,  which is not only a great disfigure-
ment, but a cause of the serious annoyances already specified.   This
is done by an operation,  which consists, first,  in the formation of a
flap with the cataract knife: and,  secondly, in  completing the cir-
cular  excision of the most prominent portion of the tumor with a
pair  of curved  scissors.   The  lens  and  viteous  humor escape;
the  eye shrinks  into the orbit; and, though the organ is destroyed, 
34
DISEASES  OF  THE EYE.
the patient is freed from a disease, which, besides being  attended
with total loss of sight, was a source of great misery and suffering.

                           SYNECHIA

Is a term employed to signify a morbid adhesion of the iris.   When
the adhesion is to the cornea, the case is called synechia anterior;
when to the capsule of the crystalline lens, synechia posterior.   The
former is often the consequence of a wound,  or ulcer of the cornea,
attended with  escape  of  the aqueous humor; the latter is more fre-
quently brought  on by iritis.
   Partial and  recent adhesions of the iris to  the capsule of the lens
may sometimes be separated by the use of belladonna and mercury.
In some instances of  partial  synechia  anterior, and  even of com-
plete synechia posterior, which is mostly  attended with  closure of
the pupil, vision may  be restored by the formation of an artificial
pupil.
   The adhesion of the iris to the cornea produces a change  in the
size,  position, and  shape of the  pupil; and  when the result of in-
flammation, or of a prolapsus of the iris, the cornea mostly becomes
opaque.

                   PROLAPSUS  OF  THE  IRIS,

Sometimes termed staphyloma  racemosum,  is a protusion of the
iris  through  a wound  or ulcerated opening in the cornea.   It is
necessarily of the same  color as the iris, brown or greyish, and its
size varies from  that of a pin's head to that of a small pea.   As the
cornea is rarely  perforated at more than one point, the  prolapsus is
usually single, and its  base is generally  surrounded by  an opaque
circle of the cornea.
   The inconveniences of a prolapsus of the iris, are, pricking pain
in the eye, inflammation of the organ, intolerance of light, a devia-
tion of the pupil towards the seat of the prolapsus,  and a  lessening
of its diameter.   In cases of long standing,  the  protruded portion
of the iris becomes less sensible,  and the distress  experienced less
acute.
   When the prolapsus is quite  recent, and  the consequence  of a
wound, no doubt can exist about the propriety  of reducing the iris
into its right situation again.   In other examples this is impractica-
ble, and then  the inconveniences  of the projection of the iris are to
be relieved by  touching the tumor repeatedly with the nitrate of
 silver, until  it  is sufficiently  levelled and the ulcer healed; while
the obstruction of vision itself, caused by the displacement and ul-
ceration of the pupil, and  the partial opacity of  the  cornea  may
sometimes  be removed  by the formation  of  an  artificial  pupil. 
CLOSURE  OF THE  PUPIL.
85
When the protruded piece of the iris is large, it may be necessary
to snip off a part of it with scissors, before the nitrate  of silver is
applied.

CLOSURE OF THE PUPIL,  AND  FORMATION  OF AN  ARTIFICIAL
                             PUPIL.

   A permanent contraction, or a closure of the pupil,  is most fre-
quently a consequence of inflammation of the iris, but sometimes it fol-
lows operations for the removal of cataracts, coming on slowly and
insidiously at some  indeterminate  period  afterwards,  without any
marked inflammation in the eye.  The iris  becomes motionless,  as-
sumes a radiated wrinkled appearance,  and,  when  the lens is free
from  opacity,  a small black point  is  seen in its centre.  Under
these circumstances, if  the  retina be sound, the patient may some-
times regain  a considerable  power of vision by the formation of an
artificial  pupil.  The pupil  may also be obstructed by the effusion
and organisation of coagulating lymph from inflammation; or there
may be such a displacement of the  iris from prolapsus as  causes an
alteration in the shape and position of the  pupil, attended with  se-
rious  obstruction of vision.
   The several varieties of operation  for the formation of an artifi-
cial pupil may all be  referred to  three principal methods; the first
is a simple cut  through  the iris,  without  the removal of any por-
tion of it, termed coretomia.   The  second  is an incision in the iris,
and the removal of a  part of it—corectomia.   The third consists in
separating some of its external margin from the corpus  ciliare—cor-
edialysis.
   It is manifest that none of these operations can be performed with
a  reasonable  prospect of success, except when the  changes in the
condition of the pupil are  the only defect in the eye.   Thus, unless
the retina were sensible, it would  be doing  no  goo:«l to make a new
opening in the iris.  The patient should always be capable of discern-
ing the dilierence  between  light and  darkness;  and, if he had not
this power, the operation would hold out little prospect of success.
This  state, however,  does not amount to an absolute  prohibition  of
it, because sometimes the iris is so thickened, the posterior chamber
so full of dense lymph, and the transparency of the lens so affected,
that the power in question may be annihilated, yet the retina  itself
not be incapable of resuming its functions.   The experiment, though
unpromising, may be made.
   An artificial pupil should  never be formed in one eye, so long as
the patient is able to see with  the  other.   Nor ought the  operation
to be  attempted  if the eye be affected with  inflammation,  preterna-
tural hardness, dropsy, or atrophy.
   When a part of the cornea is opaque, the  place for the artificial
pupil  must, of course, be determined  by the situation of the trans-
   vol. n.                    8 
86
DISEASES  OF THE EYE.
parent portion of that membrane; and if the operator has the choice
of placing it behind either the nasal or the temporal edge ol the cor-
nea, the former situation is to be preferred, as affording a more use-
ful degree of vision.                                     . f
  Whenever the lens and capsule are  transparent, one chief  cau-
tion  in  the operation.is  to  leave  those  parts  completely undis-
turbed.                                     .         .      , ...
  As an artificial pupil  possesses no power of contraction  and dila-
tation, care must be taken to make-it neither too large nor too small.
Too small an opening would  not be  very serviceable; and  il  it were
too ample,  the  quantity of light admitted  into the eye would dazzle
vision, and the new aperture  be comparatively useless.
  The limits of this work prevent me from  describing all the modi-
fications of operations,  rendered necessary by the mfinite variety of
circumstances  attending a closure of the pupil.   The state of the
pupil itself;  its being  filled or not by opsque fibrine; the  condition
of the cornea;  the,state of the lens; and the disease being compli-
cated or not  with prolapsus  and adhesion of the iris, are  several
principal considerations materially influencing the particular mode of
operating.                                                 „
   Coretomia, or the  simple  division of the ins, may be periormed
with an  iris-knife, or  coaching-needle, that has a sharp edge only on
one side;  or else with a minute pair of  scissors, one blade of which
has a sharp point, the other an end,  like that of a small probe. The
iris-knife, which is  but little larger than  a  common couching-needle,
is introduced through the sclerotica, about a line and a half from the
cornea; and, after perforating the iris on the side towards the tem-
ple, its  point is conveyed across the anterior chamber nearly as far
as the ciliary margin  of the iris towards the nose.   Then  the sharp
edge is  to be turned backwards, and pressed against the iris as it is
withdrawn, so as to make a transverse cut in the iris.
   Another  plan of dividing of the iris is performed  by making an
incision near the side of the  cornea, and introducing small scissors,
one of the blades  of  which has a  sharp point, the other a probe
point.  The sharp point is then passed through the iris, near its cil-
iary margin; while  the  probe point  is passed under the  cornea, the
requisite distance, when the  blades are  to be shut, and the  necessary
division of the iris  executed.
   These methods of operating are  proper when the iris has a tense
appearance, when the cornea is transparent, and there is no crystal-
line lens, or when the closure of the pupil  has followed  extraction
of the cataract.
   The excision of a portion of the iris, termed  corectcmia,  is an-
other method.  It  is performed in  different ways.   Thus,  we may
.puncture the cornea, draw out a piece of the  iris  by  means  of a
minute  hook, made for the purpose, and snip it off.  This was  Pro-
fessor Beer's way, which appears quite as  good as that adopted by 
         HYDROPIITHALMIA, OR DROPSY  OF EHE  EYE.       87

the late Mr. Gibson, who made an  incision in the  cornea, so  as to
let out the aqueous  humor, after which he  made a piece of  the  iris
protrude by means of gentle pressure, and cut it off.   The iris then
receded into the eye with the new circular  opening formed in it.
   These last plans are proper when the centre of the cornea is dense-
ly opaque,  but  the whole, or a  portion of  its circumference, trans-
parent, and the lens and its capsule sound.
   The operation of separating a portion of the outer margin of  the
iris from the corpus ciliare, coredialysis, was first  done by Scarpa,
on the side  towards the nose;  but,  as the opening did not continue
to be permanent, this plan was  abandoned  in favor  of Reisinger's
method, which is executed by means of a very  fine double-hook
forceps, capable  of being put into the form of a single hook by  slight
pressure.   A small puncture is made in  the cornea near its  margin,
the double-hook- forceps introduced, and conveyed,  with the points
turned downwards, as far as the place  where the iris  is to be separ-
ated, but always  as r.ear as possible to the  ciliary edge.  The points
are then to be slightly  opened, and made  to enter the  iris.  The
blades are  now  to  be shut, and the instrument  slowly drawn  out-
wards, by  which means a sufficient piece of the iris will be  detach-
ed, which,  having been disengaged  from  the instrument, is to be  left
strangulated in the wound of the cornea.  In fact, this operation is
a combination of coredialysis  with corectomia.  In this country,
coredialysis is not mueh in favor, surgeons generally preferring  either
coretomia or corectomia.

         IIYDROPHTHALMIA,  OR DROPSY  OF THE  EYE

Seems to  be generally  a local disease, or, at all events, is  never
connected  with, or dependent upon, ascites, anasarca, or other drop-
sical  affections;  and, if it depend upon  constitutional causes, their
nature has  not  yet been  made out.  There may be dropsy of the
chambers of the  eye, that is, an increase in the quantity of the aque-
ous humor; or there may be  a preternatural  accumulation of the
vitrjeous humor;  or, lastly, there may be a  collection  of  serous fluid
between the sclerotic and choroid tunics.
   The symptoms of dropsy of the anterior and posterior chambers
area greater prominence of the cornea than natural, and an increase
in its  diameter,  attended in the advanced stages with loss  of it3
transparency.  The iris is soon rendered motionless, and of a dark-
er color than usual.   At first,  ihe eye is far-sighted,  but afterwards
the  power of   seeing  becomes  considerably  impaired,  or  lost.
When this  variety of hydrophthalmia follows injuries of ihe eye,  it
may be  combined with a  tremulous state of the iris,  and  partial
amaurosis.
   In the treatment, we may try blisters on the temple, or behind the
ear; mercury, iodine, and purgatives.  In inveterate cases, paracen- 
88
DISEASES OF THE EYE.
tesis oculi has sometimes been practised.   If this plan be adopted,
the best instrument is a grooved needle.   I had a case in University
College Hospital,  in which I punctured the eye seven or eight times
at intervals with such a needle, so as to discharge the fluid,  and  at
length to diminish  the size of the organ, and relieve the patient from
the severe pain previously experienced.
   If  the existence of subsclerotic dropsy could be made out, the
discharge of the fluid by puncture would be indicated.
   Dropsy of the vitreous humor is attended with enlargement of the
posterior part  of the eyeball, a conical projection of the cornea for-
wards, advance of the iris towards the cornea, deep blue color  of
ihe sclerotica, and shortsightedness, followed by  complete amauro-
sis, the eyeball becoming hard and motionless.
   As the eyesight is totally  lost,  all that the surgeon can do is to
relieve those inconveniences  which arise from the  distended state
of the eye, and its pressure.   If puncture with the needle were in-
sufficient, a piece  of the cornea might be cut off, and the  humors
discharged.

                AMAUROSIS, OR  GUTTA SERENA,

Is an obscurity or loss of vision, arising from a  more or less  insen-
sible  state of the retina.  Either the retina, the optic nerve,  or the
brain, may be the part first and principally affected.   The expression
gutta serena is only applied to cases of total blindness, plainly derived
from  the circumstance of the pupil having no opacity  in it, and be-
ing apparently clear,  though the patient is blind.
   The symptoms  of amaurosis are of two kinds  : first those  which
the surgeon notices in the form, color, texture,  consistence, vascu-
larity, and  motions of the different parts of the organ, or in the gen-
eral condition of the patient;  secondly, those which the patient him-
self experiences, as  impaired or deranged vision, headache, vertigo,
peculiar  sensations in the eye,  &c.
   The first symptom, and  one that never fails to be present, is the
patient's want of a proper control over the eye  affected, the pupils
of the two eyes not being directed harmoniously to the objects look-
ed at; and hence, there is  a  kind of staring and  vacancy  in the
countenance.   This symptom may exist at first only in a very slight
degree;  but, in some  cases, it amounts to  an actual squinting, or
strabismus; while, in others, such is  the  want of control over the
eye,  that it is either affected with oscillation or stands quite motion-
less in the  orbit.   The motions of the eyelids,  as  well  as those of
the eyes, are  likewise not  unfrequently interrupted; sometimes the
levator of  the upper eyelid being  palsied, and sometimes the orbic-
ularis palpebrarum.
   The eye may also form  a  greater prominence  than the other, or
be otherwise changed in its  shape.   Its  color  is  seldom that ex- 
AMAUROSIS,  OR GUTTA  SERENA.
89
hibited  in  the healthy state, the sclerotica being  yellowish,- bluish,
or ash-colored, and often streaked  with varicose  vessels;  while  no
symptoms of amaurosis is more to be depended upon,  than  an  in-
crease or diminution in the natural  firmness of the eyeball.
  Another usual  symptom is a sluggish and limited  motion of the
iris, generally attended with dilatation of the pupil, but occasionally
with  contraction.   The early and  incomplete stages of amaurosis
are, indeed,  rarely accompanied  by a  widely dilated pupil; but,
after the perception of light  has  become further weakened  or ex
tinct, the opening is  commonly expanded and  quite motionless.
Vet,  cases sometimes  present themselves, in  which the pupil of a
completely amaurotic  eye will move  briskly, according to  the de-
gree of light  acting upon the opposite or sound eye;  though, if the
amaurotic eye  alone  were exposed to its  influence,  the pupil of it
would remain perfe tly motionless  and  greatly  dilated.  Hence, it
is a rule in surgery, always to close and  cover the sound eye dur-
ing the examination of ihe  state of  the iris and  pupil of an eye sus-
pected  to be amaurotic.   Other examples still  more curious occur,
in which, though the  patient is totally  blind,  both  pupils  vary  in
diameter, according  to  the  changing  degrees  of light, exactly  as
they do in the perfect state of the eyes.
   Besides the motions of the iris, which must be examined  in each
eye separately,  and with the  opposite eye excluded from the light,
the s!;apr? and situation of the pupil should be noticed, and the incli-
nation of the iris  considered; lor sometimes the  pupil is irregularly
dilated,  and  sometimes moved  towards  a particular point of the
circumference  of the iris,  while this  membrane  itself may either
bulge  out towards the cornea, or sink back, so as to present a con-
cave  appearance.
   When amaurosis is an effect of hydrocephalus in a young subject,
the pupil may exhibit  its  naturally black  hue; but in elderly subjects,
amaurosis is  almost constantly accompanied either by some degree
of glaucoma, or a dull glassy, or horny appearance in the  pupil.
   As for the symptoms  or effects, of which  the  patient alone is
conscious, there  is, first, impaired  vision,  the  progress and  degree
of which vary in  different cases; for, in some instances, the patient
b comes  suddenly and  permanently blind, while,  in others, the
sight  diminishes in a  scry slow and gradual manner,  without ever
terminating in total blindness.
   Hence, the  distinctions of complete and incomplete amaurosis.
Frequently,  in the commencement of  the disease, the  failure  of
s:ght  is on'v  occasional,  or  for a  short  time, or  periodical, assum-
ing the form  of night  blindness or day blindness, or coming on after
any g;-eat exertion of  the eyes.  A few lines of a printed book may
perhaps be read., after which the letters appear completely  confused.
The failure  of sight may extend  to the whole field of vision,  or
only to a part of  it.   Thus more or less of the  page of a book may 
90
DISEASES OF THE EYE.
be visible (visus interruptus),  or only the half of objects may be
seen (hemiopia).  Sometimes objects can be seen only when plac-
ed exactly in one  particular direction  (visus obliquus).   To some
amaurotic  patients all objects  seem  disfigured, crooked,  enlarged,
diminished, or even inverted (visus defiguratus).
   Then another common sign of amaurosis, which the patient per-
ceives,  is what  are termed ocular spectra, as  sensations of flashes of
light in the eye (photopsia), or of insects or cobwebbs flying about
before  the eye (muscae volitantes);  or of colors which are not be-
fore the eye.   Double vision is also another frequent effect  of the
disease  in its early stage.   As the  complaint advances,  however,
vision is obscured  by one uniform cloud or network.
  In the early  periods, the  patient has sometimes an unwonted sen-
sibility  to light, which even gives him pain; while,  in other more
usual cases, he always courts  it from  the very beginning.  Pain in
the eyes, head, and face is another important symptom in amaurosis,
denoting the probability of  the existence of slow  inflammation of
the retina, or of organic disease within  the cranium itself.   In fact,
several  of the incurable forms of amaurosis depend on causes,  which
act on the nervous structure of the eye  from within the skull.   Such
are collections of  fluid in the ventricles of the brain; disease or
tumors  of this organ, situated near that part of it  where  the optic
nerve is connected with its  base; while other swellings or diseases
may affect the optic nerve in its course  either within  the cranium,
or in the orbit.
  Loss of sensibility in the  retina, and a complete  annihilation of
its functions, may be the effect or accompaniment of other diseases
of the eye ; as, for instance, of the severe varieties  of ophthalmy
affecting the interior texture  of the eye, glaucoma, hydrophthalmy,
melanosis,  and  fungus haematodes.   These  examples, in  which
the retina suffers, in  common  with  other textures,  are named ac-
cording to the  primary  disease,  or to  their most prominent  symp-
toms; and  when we use the  term  amaurosis,  we commonly under-
stand a  case, in which the retina, or nervous  apparatus of sight, is
the part of the eye first affected.
  Immoderate  exertion of the eye, more especially  on  small ob-
jects, and in  persons either of  plethoric constitution,  or intemperate
habits, producing a determination of blood to the head, may  be set
down as frequent causes of  a slow inflammation  of the retina, end-
ing in an alteration of its texture, and in  impairment  or abolition of
its  functions.   Hence  printers,  watchmakers,  engravers, tailors
and other classes of workmen, whose eyes are employed on minute
objects  and needlework, are frequently afflicted with amaurosis.
   Amaurosis is sometimes divided into functional and organic the
first implying the interruption of  the  functions of the  retina, inde-
pendently of any organic disease.  Whether  such   case really oc-
curs has sometimes been disputed; but if we admit that  amaurosis 
AMAUROSIS.
91
may arise from sympathy of the eyes with disease or irritation in
distant parts, we  must, I believe, admit the doctrine of functional
amaurosis.  Thus amaurosis may arise  from  gastric disorder, the
presence of worms in the bowels, the irritation of dentition, or that
of a carious tooth.   The disease may also be excited  by  a wound
of the scalp, caries of the  skull, disease  of the  antrum, abscesses
about the face, the  suppression of the menses, or the effect of par-
ticular aliments in persons of peculiar idiosyncrasies.
   With  respect  to the prognosis, the  functional  amaurosis  must
leave a greater hope of cure than the organic.  A suddenly formed
amaurosis  is generally less unfavorable, than one  that has developed
itself slowly.   Complete inveterate  amaurosis,  attended  with or-
ganic change of the retina, or optic nerve, may be deemed incura-
ble.   The distorted appearance of objects in  the early stage is al-
ways a bad omen, because indicative of diseases in the brain.
   Amaurosis  may  be  combined with  glaucoma, or with  cataract.
The characteristic  differences between the latter  and amaurosis will
be explained under the  head of  Cataract.
   Treatment.—No doubt much of the difficulty  of  curing amauro-
sis arises from our  frequently  being ignorant of its causes; to  their
being in  many instances various, complicated, and incapable of re-
moval; or, if removable, to  the impossibility of obviating their ef-
fects on  the retina.
   When amaurosis is attended by signs of determination  of blood
to the head, such as headache, vertigo, flushed countenance, and ar-
terial throbbings  of the  temples; when the pulse is full, and the sub-
ject young and plethoric; general and local blood-letting, purgatives,
and low  diet,  are indicated.   If the case  he  altogether  dependent
upon vascular distension, these means conjoined with rest of the or-
gan,  will probably effect a cure.  If, along  with vascular fulness,
there be effusion, depletion will also be the most  likely means of re-
lief, and  the best preparation of the patient for other remedies, more
esp3cially for the use of mercury.
   When functional amaurosis depends upon disorder of the chylo-
poietic viscera, habitual costiveness, and an increased flow  of blood
to the head, purgatives, assisted by  bleeding, are  found to answer
bettor in this country than nauseating doses of tartrate of antimony,
so  highly praised by Ritchter and Scarpa.  We may give the blue
pill at night, and  a mild saline  aperient mixture in the morning;  and,
after having continued this treatment for some time, tonics may  be
prescribed with advantage, as sulphuric acid, bark,  and steel med-
icines.
   Many examples of amaurosis depend upon  the effects of chronic
inflammation on the retina, or upon  a slow and gradually-produced
deposition of lymph  in  various  situations affecting the  immediate
organ of vision.  Now, for the diminution and removal of such ef-
fects, we know of no medicine that is at all equal to mercury.   I 
92
DISEASES OF THE EYE.
 fully agree with Mr. Lawrence, that the right treatment of most ca-
 ses of amaurosis turns upon  two  poims,  viz.—:he  employment of
 ordinary antiphlogistic means, and letting these be quic klv conjoined
 with, or followed up by, the use of mercury.   Here it acts in the same
 way as it does in  iritis; and, in order to give it a fair trial, the system
 must be kept under its influence  for a month cr six  weeks.   The
 influence should also be such as is indicated by a moderate  degree
 of salivation.   Perhaps,  I may say,  with  respect  to nine out of
 every ten cases of  amaurosis, that if they will not yield  to a com-
 bination of antiphlogistic and mercurial treatment, they will yield to
 nothing that has yet been.discovered.
  We ought, indeed,  to  modify such treatment  according  to  cir-
 cumstances.   Thus, if the patient were of  weak  frame, and appa-
 rently affected  with more gastric than  cerebal  disorder, we  should
 employ,  perhaps,  local bloedirg, rather than . venesection;  and
 moderate  doses of the blue  pill, or  compound  cajomel  pill, with
 saline medicines,  in preference to the active exhibition of calomel,
 or the  free use  of mercurial ointment.
  In some (cases, we may apply a blister, qr seton, to the  nape of
 the neck or temple.
  The plan of treating amaurotic eyes with electricity, or stimulating
applications, and tonics, is found to be generally unsuccessful. The
 idea of amaurosis being essentially connected with debility is erro-
neous.   The only exception to this  remark  may  be the  amaurosis
from suckling, and from profs:; loss of blood.  However, galvanism
has now and then been applied to  the frontal nerve with advantage.
 If a delicate female were to lose, first, her health, and then become
 amauiotic, from suckling  a hearty child, of course the  best  plan
 would  be to wean it, and give her tonics  and a light nutritious diet,
 with a  small quantity  of wine daily.    In  some instances, applying
 from half a  grain to two grains of strychnia, to  a blistered part of
 the skin behind the  ear, or over the frontal nerve, has been produc-
tive of decided benefit.

            IIEMERAL0PIA, OR NIGHT  BLINDNESS,

 Is an incomplete and periodical amaurosis, exemplifying,  according
to my judgment, the reality of functional cases.   The patient enjovs
good vision  all the  day; but  after twilight he becomes blind.   No
 sooner, however, does the  sun arise, than the affection of the optic
nerve and retina goes  off', and  the  patient then sees very well a^ain.
 It is only in the tropics that  hemcralopia is likely to be  met with:
 in this climate,  examples of it  are rare, and,  when they do occur,
are  generally relapse; in persons who have been previously affected
 in hot  countries.   The disorder  is easily cured  by blistering  the
 temples,  and mild antiphlogistic treatment. 
CATARACT.
93
                         NYCTALOPIA,

Signifying blindness during the day and vision by night, is described
by writers, but is so rare, that few  surgeons have  ever seen an ex-
ample of it.   Larrey records a case of it in an old man, one of the
galley-slaves at Brest, who had been shut up in a dark subterraneous
dungeon for thirty-three years.   When he was released, he could
only see in the shade of night, and was completely blind during the
day.  Ramazzini also mentions an epidemic  day blindness, which,
in his time,  attacked  boys in Italy, about  ten years of age.  But,
though  we do not  meet with nyctalopia in  England as an original
disease, we know  that great intolerance of daylight is one of the
common effects  of scrofulous ophthalmy.   The photophobia,  or
aversion to light,  exemplified in the  albino, is familiarly  known.
Day-blindness is  also  noticed as  a  symptom of  mydriasis, or a
simple preternatural dilatation of  the  pupil.   Patients, who have
incipient cataracts, see  very  little in the brightness  of day, but much
better in the evening, when  the light is diminished  and the pupil ex-
panded.

                            CATARACT

Is usually defined to be a  weakness  or interruption of sight, pro-
duced  by opacity either of the crystalline  lens, its  capsule, or the
fluid of Morgagni.   Occasionally,  however, the term  is used in a
more comprehensive  sense, implying  every perceptible obstacle to
vision, situated between the vitreous humor and the  uvea  and pupil.
   When the disease is seated in the lens, its capsule, or the  fluid
of Morgagni,  it  is called a  true cataract;  but, when it consists of
opaque  matter  deposited  in  front of the lens, it  is  denominated a
false cataract.   The terms, lenticular, capsular, and capsulo-lentic-
ular cataracts, express  some of the d'stinctions referred  to.  The
Morgagnian may be dismissed from present consideration,  its sepa-
rate existence not being generally credited.
   Cataracts are also distinguished into idiopathic, or such  as arise
from internal, but generally  unknown causes,—and  into accidental.
which originate from external violence, or active inflammation.   In
general, the idiopathic, sooner or later, affect both  eyes; but  an
accidental cataract is frequently restricted to one eye.
   The  symptoms of  a  cataract are of the following  description:—
1st.  All objects, especially  white ones, seem  to the patient as if
covered with a mist, a circumstance  that generally precedes any
visible opacity behind the pupil.   2d. The decline of vision bears
an exact proportion to the degree of opacity.   3d.  The opacity is
almost always first noticed in the centre of  the pupil, the examples,
in which it  first presents itself at  the circumference,  being much 
94
DISEASES  OF THE  EYE.
less frequent.  4th. When the iris is light-colored, the more apaque
tie cataract  is,  the more  plainly a blackish ring is seen at the edge
of trie pupil; and  such  a ring  is particularly conspicuous when  the
cataract is soft and large, as it then propels the margin of the uvea
forwards.  5th. As a cataract generally begins at  the central point
behind  the  pupil, objects placed directly in front of the eye  are
most difficultly seen, even in the early stage of the disease;  but those,
which are on one side, may yet be  discerned, particularly if  the
light be not  strong, which would  make the pupil  too diminutive to
let the rays pass through the thinner  transparent edge of the lens.
6th. What  I have just observed likewise explains  why  patients,
having an opacity  in the centre of the lens, are sometimes complete-
ly blind in  a strong light, though  they may enjoy a useful degree
of vision  in  the shade, or in  moderately  dark places.   7th. The
eyesight of  patients, affected with incipient  caUract, may be ma-
terially  assisted with convex glasses, because objects are  magnified
by  them.  8th. To patients  in this  state, the flame of a candle
seems to be obscured in a white misty halo, which always becomes
broader the further the  patient  is from the light.   When the cataract
is more advanced, the   flame cannot be discerned, but merely the
place of the  light.  9ih.  The action of the iris is  not affected.
  In amaurosis, the horn-like or glaucomatous  appearance is more
deeply  seated  in  the eye than the opacity  of a  cataract, and is
somewhat  concave.  It is frequently of a greenish color, while the
opacity of cataract  is  usually  greyish,  white, or  amber-colored.
The decline  of vision, also, is  not in a ratio to the  opacity, and the
patient may be entirely  blind, with little appearance of defect in the
eye.   The pupil is likewise  generally dilated  and  motionless, with
its pupillary margin somewhat  irregular.   The temporary increase
or decrease of  blindness, a  circumstance so  common in patients
with incomplete amaurosis, depends upon circumstances  which de-
press or excite the system, and not, as in cases of cataract, upon
the degree of light, and the corresponding alterations  in the size of
the pupil.
  The  misty halo, seen by amaurotic  patients round  the flame of a
candle,  is not like a whitish cloud, as in cases of cataract, but ex-
hibits all the  colors of the rainbow.   To amaurotic  patients spec-
tacles are of no service;  and  objects situated  on one side are not
better seen by such persons, than  those which are  directly in front
of the eye.   Neither is  there any temporary  increase  of the power
of vision obtained  by the use of belladonna, as  in cataract.
  Whiteness denotes either a  dissolved lens or a capsular cataract;
a grey color, a lenticular cataract;  an amber  color or dark grev, a
firm lens; and light grey, a soft one.   If the whole extent of"the
pupil  is uniformly  opaque, tlu cataract is probably one of the lens;
if the opacity is streaked  or speckled, it is likely  to be one of the
capsule.  If the opaque streaks radiate from a centre, the posterior 
CATARACT.
95
layer of the capsule is probably affected.  If the form of the opaci-
ty is convex, either the anterior capsule or the lei.s is the seat of it;
if concave, the posterior part of the capsule.   With the light con-
centrated on the  pupil  by means  of a double  convex  glass,  all
these particulars may  be ascertained.  I believe,  that the size of a
cataract is  a better criterion of its consistence than its color is; and,
at all events, that  the  smaller the  ler.s is, and the darker its color,
the more solid  its  substance will  generally be;  while the larger and
more protubereut  it is against the iris, the greater is the probability
of its being soft.
   A cataract of the lens itself, as I  have already explained,  is term-
ed  a lenticular  cataract, which may vary much in  its consistence.
Thus, such a cataract may be hard, as it is often  found to be in  el-
derly persons,  with  an  amber  cclor,  the tint being deeper in  pro-
portion as the cataract is firmer.
   A lenticular cataract may be svft,  that is to say, of  a  cheesy,
gelatinous, or even  milky consistence.  Soft cataracts  are more
bulky than hard  ones,  so  that they  project nearly into  the pupil.
Hence,  sight is more  considerably  interrupted than when the cata-
ract is hard, and the  power of distinguishing  colors frequently quite
abolished.   The  capsular cataract  has a smooth  and glistening sur-
face, with streaks upon  it, and it  lies close to the edge of the pupil.
   When the lens is  present,  a capsular cataract is rarely  unaccom-
panied  by a lenticular one; but an opaque lens may be removed  or
taken away by absorption, and a  capsular cataract may Le left.   In
this case,  as the opacity is  merely  a thin layer of the capsule, the
cataract makes no projection  against the iris, and the anterior cham-
ber is not  lessened by the advance of the iris towards the cornea.
   In children, cataracts are  never  hard : but in adults,  we meet
with bo|h  hard and soft  ones.
   Cataracts may  occur  in any  period of life, and are sometimes
congenital.  They are  most  frequent in elderly persons, and most-
ly arise  without any manifest  cause,  or any thing  wrong in  the rest
of  the  eye, or the  constitution  at  large.   The  capsulo-lenticular
cataract is alleged to  form  very commonly under circumstances de-
noting a determination of blood  to  the head and the eye, accom-
panied  by uneasy sensations in those parts; but  generally  we can-
not refer the origin of a cataract to any particular causes.   There
is an exception, with  respect to cataracts following a wound of the
lens, or its capsule.   Experience proves that the slightest  prick of
these parts will lead  to   their opacity, or rather,  1 should say, that
the capsule inflames,  and becomes  opaque,  and the lens itself is  af-
terwards absorbed;  so  that  the  result is,  in fact, a  capsular cata-
ract.
   A cataract is termed  simple when accompanied by no  other dis-
ease of  the eye likely to impair  its functions, or  with  no particular
constitutional disease; complicated,  when joined with other diseas- 
96
DISEASES  OF THE EYE.
es of the  eye, as  adhesion of the  crystalline capsule to  the  iris,
amaurosis, glaucoma, or a gouty,  rheumatic, or syphilitic state of
the system.   The circumstances denoting glaucoma have already
been explained.  If,  in addition to a sluggish or immoveable iris,
the patient is totally incapable of distinguishing the least glimpse of
light, the  cataract  is combined with amaurosis.
   When a cataract is free  from every complication; when  it is not
attended with frequent headache, nor pains in the  eye; when the pu-
pil retains its regular circular shape; when the iris possesses its na-
tural power of motion in the different degrees of light; and  when
the patient  can readily discern the  difference  between  light and
darkness, and even perceive  bright colors, and  the outlines of ob-
jects, in shady places where the pupil naturally expands—the prog-
nosis is favorable.
   There are no medicines, nor applications, capable" of dispersing
an  opacity of the lens, or its capsule.   The cases,  injudiciously
blended with the subject of cataract, under the  name of false  ca-
taracts, which are only obstructions of the pupil  with fibrine, effus-
ed in consequence of inflammation,  may indeed  sometimes  be  ben-
efited,  or  even cured, by the means recommended for  the cure of
iritis; but no  real analogy exists between such  cases and opacity
of the lens and its capsule.  In all examples of true cataract,  it is
only by an operation that sight can  be restored.
   Whether an operation should be  performed when the cataract is
single, and the other eye  in  the enjoyment  of  good  vision,  is a
question on which some difference  of opinion is entertained.  Di-
versity in the refracting powers of the eyes after  the removal of the
lens from  one of them, and the apprehension of confused vision, as
the result, are the  reasons usually urged against the practice, which
has, however, to a  certain  extent, proved successful; while  the
continuance of a cataract in one eye not only gives a disposition  to
the origin of  the same kind of opacity in the other, but permanent-
ly impairs the sensibility of the retina itself for want of exercise.
   It is a general rule, and  I believe an excellent  one, never to op-
erate upon both eyes at  the  same  time.   In particular, when ex-
traction is to be done, this  maxim universally  prevails.   It is  also
a maxim to let the patient have the benefit of preparatory treatment
before  he  undergoes the operation.   His diet should be lowered
and his bowels emptied.
   In cases of congenital cataract, ought the operation  to be delay-
ed till the patient has  attained  the age of docility and reason?   Or
ought it to  be  practised  in early  infancy?  Every consideration
seems, I think, to  be in favor of an early performance of it.   If it
be postponed, the  eyes, having  no  distinct perception of external
objects, acquire such an inveterate  habit of rolling, that  for a  long
time after the pupil has  been cleared by an operation no voluntary
effort can control this irregular motion.  The retina, too, by a law 
CATARACT.
97
common to all structures of an animal  body, for want of being ex-
ercised, becomes more or less deprived of power.  From the age
of eighteen months to that of two years is deemed an advantageous
period for operating on congenital cataracts.
   Persons blind from congenital and other cataracts of long dura-
tion, and habituated to live with four senses, are generally confused
and perplexed on  the restoration of vision.  They have a difficul-
ty in combining the action of the eye with that of the other senses.
Hence Dupuytren  has often found  it necessary  to  deprive them,
for a time, of the use of one or two of the other senses,  in order
to enable them to use  the organ of vision.   He has  applied this
principle to infants, by closing their ears, as it  was noticed  that
they suffered themselves to be guided by sound, and  by impressions
received by the  hands, which they thrust  out before their bodies
like tentacula.
   There are three  kinds of operation  for cataract.   1st.  The me-
thod formerly termed couching, and which is simply the removal of
the cataract out of the axis of the vision, leaving it still in the eye.
 It is now frequently called displacement;  and has two varieties, de-
pression and reclination.  2d.  Surgeons  practice extraction of the
cataract; that is, they take  the opaque lens completely out of  the
eye.   8d. Another method  often adopted  consists in the division
of the cataract into fragments, which, being exposed to  the  aque-
ous humor, become absorbed.
   By depression and reclination, we change the situation of the  ca-
taract.   In depression, the lens is pushed  directly below  the level
of the pupil.   In reclination, the lens is made to turn over into the
middle, and towards the  bottom of the vitreous humor;  so that the
surface of the lens, which was previously directed forwards, is now
placed upwards, and what was the upper edge is turned  backwards.
Over the  lens, displaced  in  this  manner, the vitreous humor will
close much more completely than over the simply depressed  lens,
so that its  ascent behind the  pupil again will  be less likely to hap-
pen.   Nor will the retina be so  liable to  be pressed  upon by the
cataract as after depression; yet, reclination unavoidably does more
extensive injury to the hyaloid membrane of the  vitreous  humor.
   Extraction  is the complete removal  of the cataract out  of the
eye through an  opening made in the cornea.  The incision for  this
purpose must form the segment of a regular circle, be smooth, and,
at the same  time,  of sufficient  size to  permit the easy passage of
the cataract through it.   Both in this  first period of the operation,
 and in the subsequent one of opening the capsule, the  iris should
 remain entirely free from injury.
   One of the chief dangers of extraction is that of loss  of the vi-
 treous humor, which, if due care be  not  taken, is apt to  be sud-
 denly forced out of the eye along with the cataract.
    Another risk is  that of the iris being wounded.   Sometimes the
    VOL. n.                   9 
98                  DISEASES OF THE  EYE.

operation is followed by a prolapsus of this organ, and occasionally
by a closure of the  pupil from the inflammation excited  in  the iris
by injury of its texture.
   The "division, or breaking of a  cataract piecemeal, may be done
with a needle, either through the sclerotica or the cornea.  It has
the recommendation of being the  most easy, but  sometimes needs
repetition.  Opaque portions of the capsule, however,  frequently
resist absorption, and must, after all, either be extracted  or displac-
ed.   The division of a cataract,  when  performed by passing the
needle through the cornea and pupil, is termed keratonyxis.
  No method of operating for the cure of cataract should be exclu-
sively  preferred;  each having its advantages in particular cases.
  Depression  and Reclination through the Sclerotica.—Each of
these operations has  three stages :—
  In the first, the needle is introduced through the coats of the eye
into the vitreous humor.
  In the second, the instrument enters the posterior  chamber,  and
is applied to the cataract.
  In the third, the displacement is effected.
  It is only in the third stage that reclination differs from depression.
  The patient is generally seated on a low stool, with his head sup-
ported on the breast of an assistant, who  stands behind him ; and,
if the operation  be about to  be done on  the left  eye, he puts his
right hand under the patient's chin, while  with the index and mid-
dle fingers of the left hand, applied to the margin  of the upper eye-
lid, he keeps it raised  against  the supercilliary ridge of the  frontal
bone, without making any pressure upon  the eyeball  itself.   In all
operations on the eye,  performed  with the needle, the pupil should
be first dilated with  belladonna, because the  more  expanded this
opening is, the better the surgeon  can  see what he is doing.   The
pupil should also generally be kept dilated  for some  time after the
operation, in order to let the aqueous humor have free access to the
lens, and to prevent  the pupillary  margin  of the iris from  contract-
ing adhesions.
  The operator sits  in front of the patient, on  a seat of such height
that the patient's  head  is  opposite to  his  breast.   If it be the left
eye which is to be operated upon, he takes the  needle in his right
hand, while, with the left fore-finger, he depresses the lower eyelid,
and at the same time puts the  end of the middle  finger just below
the caruncula lachrymalis, so  as to prevent the eye from rolling in-
wards.
  First Stage.—With the little finger resting on the patient's cheek,
the surgeon  introduces the needle one eighth of an  inch  behind the
temporal edge  of the cornea,  so  as to avoid the  ciliary  processes,
and one line below  the transverse  diameter of the pupil, so as to
avoid wounding the long ciliary artery.   For the purpose 'of avoid-
ing the lens  and ciliary  processes  more surely, the  needle  shoud 
CATARACT.                        99
be directed towards the centre of the vitreous homor, but only to
the depth of one fifth of an inch, as it would be wrong to  injure the
vitreous humor to an unnecessary extent.
   Second Stage.—One flat surface of the needle is now to be turn-
ed forwards,  the other  backwards, and  its handle inclined towards
the temple^  so as to bring its  point  between the cilary  processes
and the circumference of the lens.
   The instrument is next to be carefully  introduced  between these
parts into the posterior chamber, across which its point is to be con-
veyed, till it  arrives behind the nasal portion of the iris.
   Third  Stage.—When depression is the  method chosen, the flat
side of the end of the needle is  now to be placed upon the upper
part of the lens, the handle gradually elevated, and the point carried
downwards, and a little outwards and backwards, the proper direc-
tion in which the  lens  should be depressed, but  no further than is
necessary to  remove it from the axis of vision.  The needle should
be kept for a minute or two on the lens, and, before it is withdrawn,
we should observe whether the cataract rises again.
   Some operators turn the point towards the pupil,  and move it
freely in it, in  order to be sure that the capsule,  if left behind,  will
be  so lacerated that it will give no further trouble.
   When reclination is preferred, the surgeon alters the plan of pro-
ceeding in the third stage; and then,  instead of placing, the  end of
the needle on the vertex of the cataract, he applies  the instrument
to its front surface,  a little above  its centre,  and makes pressure
on it downwards  and a little outwards,  by  which manoeuvre  it is
made to fall backwards, as it were, into  the vitreous humor.
   If displacement be attempted on a soft fluid cataract,  no sooner
is the capsule opened with the  needle, than its contents  mix  with
the aqueous humor.  In a day or two,  however, this fluid will be-
come clear again; but, unless we break the anterior  portion of the
capsule,  before we withdraw7 the needle, vision  will still be  inter-
rupted by the capsular part of the cataract.
   After the  operation, the eyes are  to be  shaded by means of a
slight compress, pinned to the nightcap.  The room is to be kept
moderately dark,  and  a  low diet  and  quietude  strictly  enjoined.
After three or four  days, a green shade may  be put on; but  the
eyes are not  to be used at least for a  fortnight.
   Extraction of the cataract through an  incision in  the cornea is
divided into three stages :—
  In ihe first, the cornea is opened with a  knife ;
  In the second,  the anterior layer of the capsule is divided ;
  In the third, the cataract is taken out of the eye, or extracted.
  The eye is to be  fixed,  as already explained; unless the surgeon
choose to place the  patient in the recumbent position,  with the in-
tention of dividing the upper segment of the cornea, while he fixes
the upper eyelid himself: a plan which has  its advantages, and  the 
100               DISEASES  OF  THE  EYE.

merit of first  practising  which  belongs,  I believe,  to Mr.  Alex-
ander.
   First Stage.—1. The point  of the knife  is to enter the cornea
very near the sclerotica,  and a  little above the horizontal  diameter
of the cornea.
   2.  It  is first to be directed rather towards the iris, until it reach-
es the aqueous humor, so that there may be no risk of its gliding be-
tween the layers of the cornea,  and not entering the anterior cham-
ber at all.                         t
   3.  As soon as the point is in the anterior chamber, the handle is
to be inclined  backward, and the point directed towards  the place
at which it is intended to make it pierce the corcea on the side
towards the nose.
   This place should be rather above than below the horizontal mid-
dle diameter of the pupil, and very near the  edge of the cornea.
   4.  Having performed the punctuation and  counter-punctuation of
the cornea,  as  they  are  termed,  the eye is completely under our
control.   At this particular  period all pressure is  to be  removed,
and therefore the finger, placed on the caruncula  lachrymalis, shift-
ed to the lower eyelid.   Just before the section is finished, the up-
per eyelid is to be allowed to fall, the room rather  darkened,  and
nothing more done till the patient has had a short time given him to
become composed again.
   Second Stage.—For opening and lacerating the anterior layer of
the crystalline capsule, a lance-shaped,  sharp, double-edged needle,
is the best instrument.  The assistant is cautiously to raise the up-
per eyelid, without touching the eye in  the least.   The operator
draws down the lower eyelid, and presses it very gently against  the
eyeball,  so as to  make the  cataract advance a little,  and the  pupil
expand,  but not so forcibly as to burst the hyaloid membrane.  The
needle is then  to be  introduced  under the flap of the cornea,  and
through the pupil  to the anterior layer of the capsule, which is to
be freely cut and torn in  various directions:  then the needle is  to
be withdrawn, and the eye again closed.
   Third Stage.—If the pressure made on the  lower part of the
eyeball in the second stage were continued, the lens would come out
of the eye on  withdrawing the  needle;  and  many  surgeons  allow
this  to happen.  Others  let the pressure cease for a  minute cr two,
and close the eye  again  after having divided the capsule.  They
then take the curette in the hand, which held the needle;  and having
opened the eye, and renewed the pressure, they see the whole lens
pass  into the anterior  chamber,  and then through the  incision in
the cornea.  The curette is only used, if necessary,  to facilitate its
passage through the wound.
   The patient is now to close his eye again,  and the operator,  hav-
ing received the lens on his finger nail, examines  whether it is en-
tire. 
CATARACT.
101
   After having once more opened the eyelid, and  ascertained that
the sides of the incision in the cornea are accurately in contact, and
the pupil clear and  circular, the eyes are to be shut, and a light fold
of linen is to hang down from the  cap, to which it is to be pinned.
   The patient should afterwards be  kept perfectly quiet, in a room
somewhat darkened, with a nurse to watch him, so that he may not
rub the eye with his hand during sleep.   The incision may be look-
ed at on the third day, and on the fourth the patient may be allowed
to sit  up.   On  the fifth  a shade  may be  put  on;  but  the eye
should not be used  for at least ten days, and then only  on  large ob-
jects.  The bowels are not to be disturbed  for a day or two after
the operation, but the patient should be  restricted  to  low diet for
eight or ten days.   If pain and  inflammation follow the operation,
we are to bleed the patient freely, and give calomel.   Many  sur-
geons always bleed the patient before and after the operation.
   The kind of operation  to  be preferred must  depend  upon the
species of cataract, and the sort of eye which is to be dealt with.   I
put out of  present consideration the difference of skill  in different
operators.   No doubt, extraction is the right method, when the cata-
ract is hard, and the practice not contra-indicated by the cornea be-
ing remarkably flat, the iris too convex, the eyeball small, and sunk
in the orbit, or the  space between the eyelids very narrow.   When
there are adhesions between the cornea and iris,  or  between the iris
and the crystaline capsule, extraction should not be attempted.  A
very small  pupil, not admitting  of being much  dilated, even with
belladonna,  which would be another  reason against extraction.
   The operation of division  is most  applicable to caseous or fluid
cataracts, and especially to such as occur in children.  If the cata-
ract were hard, but not proper for extraction, owing to the general
form or state of the eye, depression  should be practiced.
   The loss of the crystalline lens necessarily produces a considera-
ble diminution in the refracting power of the eye, and in its faculty of
adapting itself to the different distances of objects.   These defects
are palliated by the use of convex glasses of different foci.   Their
use however, must not commence too soon after the operation, and
never while  vision continues to be improving without them.
%
ALIGNANT  DISEASES OF THE  EYE
Are three; namely,  Cancer, Melanosis, and Fungus Hematodes or
Medullary  Cancer.
   Cancer frequently begins in the conjunctiva, whence it afterwards
extends  to  the eyelids, caruncula lachrymalis, and  the  eye itself.
The lachrymal gland,  I believe, is not so often implicated as was
once supposed;  though it is prudent to remove it  with the rest of
the contents of the orbit, when the eye is extirpated on account of
cancer.
                  *r4ss     9*
M£nIC
 
102
DISEASES OF THE EAR.
   As cancer  commences  on the external parts of the eye, and,
therefore, in its early stage, may admit of effectual removal, it  is a
less formidable disease than fungus hemotodes, which  first  attacks
the optic nerve and retina, the pupil  becoming dilated, of a  dark
amber or greenish hue, the iris motionless, and the sight seriously
impaired or destroyed from the very first.  In  an early stage of the
disease, a  white shining substance,  compared to  burnished  iron,
may be  seen through the pupil, at the back part of the eye.   As the
disease advances, this substance is found  gradually  to  extend more
and more  forwards, and to be of a solid  nature.  It is, indeed, a
medullary mass, occupying the whole of the interior of the eye be-
hind the iris, and presenting an amber or brown  appearance.   Next,
the form of the eyeball  begins to deviate  from  what  is natural; the
sclerotica  becomes of a dark  blue or livid color; and the medullary
mass  get  into  the  anterior chamber.  Lastly, the cornea or the
sclerotica  ulcerates; so  that, in the former event, the medullary sub-
stance protrudes; and, in the  latter, it forms a tumor covered by the
conjunctiva.   It is generally rapid in its growth, often attains a con-
siderable size, is of a dark red or purple color,  arid is frequently at-
tended with haemorrhage and sJoughing of its most  prominent  part.
The absorbent glands about the parotid and under the  jaw are  also
frequently  involved.   The disease, which begins in the optic nerve
and retina, and corresponds in its ungovernable and fatal nature to
fungus haematodes, or  medullary cancer "in other situations, is  very
much restricted to children.
   With few  exceptions, the   operation of extirpating  the eye  for
this disease has been of no avail.
   With respect to melanosis,  or  the  deposition into  the eye  of a
peculiar black substance, attended with total disorganisation of it, if
it  be confined  to the eyeball,  and the optic nerve is not implicated,.
the eye may, perhaps, be removed with some little more prospect
of success, than for  medullary cancer.   The  prognosis, however,.
would be bad.
                DISEASES  OF THE EAR.

  What is called earache frequently proceeds from inflammation of
the meatus auditorius, or the tympanum itself.  The pain is often re-
markably severe; a circumstance observed to attend inflammation of
all textures, whose nature  and  situation prevent them from  readi-
ly yielding to the swelling,  which is commonly the result of that af-
fection. Inflammation within the ear may proceed to suppuration, the
abscess make its way out  through the meatus auditorius externusr 
DISEASES OF THE EAR.
103
 the Eustachian tube, or the membrana tympani, or even behind the
 ear, with or without having pervaded the cells of the mastoid pro-
 cess, and occasioned caries of the bone. According to my experience,
 the  worst suppurations of the  ear occur in  scrofulous children, in
 whom they are frequently accompanied by partial destruction of the
 membrana tympani, and disease of the bony parts of the organ, fol-
 lowed in some instances by necrosis  and  separation of the ossicula.
 But inflammation and  suppuration, within the ear,  may  not only
 cause these consequences, and more  or less  complete deafness, but
 extend their effects to the dura mater,and destroy the patient. When
 exfoliations occur, they most commonly consist of the meatus ex-
 ternus, or of  the outer laminae of the mastoid  process.
   Acute inflammation of the ear demands  rigorous  antiphlogistic
 treatment.   In  adults,  copious  venesection  should  be resorted
 to;  and, in  children, leeches.   With these  means, fomentations
 and purgatives are proper, which should be followed up by blis-
 ters.
   If after the reduction of the inflammation, the discharge of mat-
 ter should continue, and the patient appear to be scrofulous, alter-
 ative medicines,  as iodine  internally and iodine lotions, or an injec-
 tion of  a weak solution of the nitrate of silver,  may be employed.
 When diseased bone is  present,  of  course  the  discharge will not
 cease till exfoliation is completed.
   The meatus auditorius is frequently blocked up, and the external
 side of  the  membrana tympani  covered  icith hard  dry masses  of
 cerumen, so as to render the patient entirely  deaf.  Such hardened
 pellets of wax,  if neglected, may  ultimately cause a great deal  of
 irritation, followed by inflammation and ulceration of the membrana
 tympani  and lining of the  passage, and  they always  give rise to a
 sensation of false confused sounds in the  ear,  which are truly dis-
 tressing.
   The cure consists in washing  out the meatus auditorius by means
 of a syringe,  capable of holding  at least four  or six ounces of warm
 water.   This should be  thrown into the passage, so as to make it
 regurgitate with  considerable rapidity.   We generally  have to do
 this several times, before the pellets are loose enough to be washed
 out.
   [The  best method  for removing masses of wax from the meatus is,
 to direct the patient to put a few drops of Bvveet oil into the ear, for
 two or three  nights,  and afterwards to syringe oul the passage,  with
 a tepid  solution of carbonate of potash.   The alkali unites with the
 oil  and   forms a soap, by which  the hardened wax is  softened, and
 easily detached.   It is wrong in  these cases, to inject water or other
 liquids with much forte.—Ed.]
  The meatus anditorius is occasionally the seat of polypi and oth-
er excrescences.   When situated near  the orifice, they  may be taken
hold of with a hook, and cut away; but,  in other cases, it is best to 
104
DISEASES OF THE EAR.
 extract them with forceps, and apply  the nitrate of silver, or tinc-
 tura ferri rnuriatis, to the part to  which they were attached.
   Extraneous  Substances in  the Meatus Auditorius  Externus.—
 When insects get into the ear, if they can be seen, the best  plan is to
 take them out at once with a pair of forceps.   If  not, we employ a
piece of lint, dipped in honey or oil,  and put on the end of a probe;
 these, on account of  their adhesiveness, will entangle any small  in-
 sect, and bring it out.  Then the passage is to be washed out with
 a syringe.   Syringing the ear I  deem the best method of all,  not
 only for insects, but for the removal of peas, small pebbles, &c.
   The regurgitation  quickly brings them out, when all other means
 fail.  One  day, when I  was visiting the Fleet Prison Infirmary, a
child was brought to me  with a pebble in each  of  its ears,  that had
been there  a twelvemonth, and had now excited violent pain and in-
flammation, attended with total  deafness.   Various surgeons had
failed in their attempts to get these  foreign bodies out.   I  immedi-
ately tried what could be done with a large syringe and had the sat-
isfaction of soon bringing the pebbles  so near  the external orifice,
that they admitted of being hooked out with a bent  probe.   In some
instances,  it has been judged necessary to  divide the  soft parts of
the meatus; but a real necessity for this proceeding  must rarely
occur.
  [There  is  sometimes great difficulty  in removing  foreign bodies
from the meatus.   After other means  have failed, we have succeeded
 in accomplishing our object, by filling the passage with some mucila-
ginous  substance, and then applying the  pipe of a pint syringe, and
making strong suction.—En.]
  Almond  or sweet oil, dropped  into the ear, soon destroys any  in-
sect lodged in it.
  Deajness from more internal causes than those which I have spe-
cified, forms too long  and complicated a subject for consideration in
a work like the  present.  It may arise from obstruction of the Eus-
tachian tube by mucus, as happens in severe  catarrh; by the  pressure
of a tumor, as is  sometimes  exemplified in cases  of polypi,  or
swelled tonsils, or in  the effects of syphilitic ulceration, or slough-
ing  sore throats.
  For the removal of deafness, caused by permanent obstruction of
the  Eustachian  tube,  Sir Astley  Cooper suggested  the practice of
making a small  puncture in the anterior and inferior  part of the mem-
brana tympani; a method that has been attended  with a degree of
success, but which  should not be undertaken without mature  con-
sideration, and  a proper discrimination  of the cases, to which alone
it is applicable.
  Diseases of the labyrinth, or of the  complicated apparatus com-
posing the internal ear, are the cases  which,  generally speaking
completely baffle the art and science pf surgery.   We scarcely ever
have any clue to their cause,  or even to the precise  parts affected 
DISEASES ABOUT  THE FACE.
105
so that no surprise ought to be  entertained at the little success with
which such kinds of  deafness are treated.
   Amongst the varieties of disease to which the labyrinth is liable,
I may mention,—
   1. Disease of the fenestra ovalis and fenestra rotunda, as ulcera-
tion and thickening.
   2. Malformation of these apertures.
   3. Inflammation of the nervous membrane lining the labyrinth.
   4. Malformation of the labyrinth, especially  of the semicircular
canals.   In two cases, examined by Mr. Cocks, the extremities of
the semicircular canals, opening into the vestibule, were perfect,  but
the central portions were impervious,  or rather  did not exist at  all.
See Med. Chir. Trans,  vol. xix.
   5. Alteration or deficiency of the liquor of Cotunni.
   6.  Affections of  the nerve  of hearing,  analogous  to amaurotic
diseases of the eye.
   When one eye, is  diseased, the other is disposed to fall into  the
same condition; but  a similar  fact  does not prevail with respect to
the ears.   Numerous persons are more or less deaf on one side,  but
the other ear usually continues its functions very well,  and even as
long as  if the other ear had no  defect.
   Every kind of deafness from malformation of the  labyrinth is -in-
curable.
   Nervous deafness  ought perhaps to be treated on principles analo-
gous to those adopted for the cure of amaurosis.  Inveterate  cases
of long  standing must, of course, be hopeless.





            DISEASES  ABOUT THE FACE.

                LUPUS, OR NOLI  ME  TANGERE,

Begins  with a tubercular induration in the tissue of the true skin, or
mucous membrane, or, perhaps, in the subcutaneous, or submucous
cellular tissue.   A single tubercle  may be  formed, or several  ap-
pear together.   While the tubercular induration is making slow pro-
gress to the surface,  the skin assumes a livid color, which extends
itself in proportion as the tubercular affection spreads, and is almost
always  followed by ulceration.   After a time, the cuticle cracks, and
a coarse laminated scab is produced from beneath  which  ichorous
matter exudes.   The scab, which is very  closely  adherent to.the
tubercle, continues to enlarge,  occasionally  falling off, and exposing
a very foul inveterate ulceration, which is found to be larger at each
successive detachment of  the crust, the limits of which  it  even 
106
DISEASES ABOUT THE FACE.
sometimes exceeds.   Dr. Houghton, who has drawn up an excellent
description of lupus, chiefly  founded on  the observations of M.
Biett*, notices three  varieties;  1.  Lupus, in which  the  ulcerative
process detroys principally in depth.  2. That in which the destruc-
tion and  cicatrisation do not produce  any open ulceration, but are
accompanied by hypertrophy of the skin.   3.  Lupus, which spreads
chiefly superficially.  The first, or  the deep erosive lupus, is more
particularly that of the nose.   In many cases, the ulceration is ac-
companied by a constant discharge of thin  fetid matter  from the
nostril of the side  affected.   The disease sometimes, indeed, com-
mences in the mucous membrane, though more commonly upon one
of the alas, or the  tip of the nose.   It may even cause a great deal
of internal mischief, without the skin  itself  being  implicated; but,
as it extends itself from within outwards, at length it approaches the
skin, which then assumes a livid  color.  But, whether it be in the
cutaneous or mucous tissue that the disease begins, its progress after
a short  time is the same.   The subjacent  cellular tissue and the
muscles  are  destroyed  by ulceration; the cartilages, in their turn,
share the same fate; and frequently also the bones.   The destruc-
tion is generally  complete  in one of the alse, or the point  of the
nose, before  it spreads  further on its  surface; but  sooner or later,
the disease extends  so as  to embrace  both  sides;  and  wherever
it advances, it is by the same kind of tubercular deposit with which
it began.   Sometimes, after  having destroyed  the tip of the nose,
or one of  the ala^ it forms a puckered cicatrix, and seems to  be
nearly healed up;-but it rarely stops in this manner, and more gene-
rally, after a  t'rr.e, new tubercles are developed  in the midst of the
cicatrix itself, which ulcerate  and  destroy  with all  their original
virulence.   In general, while the mischief is spreading externally,
the internal parts are not spared, the inner surface of the  alae, and
especially the septum narium, being attacked.   In such cases, the
discharge is constant, and  the crusts which  collect on  the  septum
and turbinated bones nearly block up the nostrils.   In  the  end, if
the disease be not  checked, all  the soft parts of the nose are de-
str(oyejj^ and the septum broken up, leaving  only a square aperture
in place ot the^n/e^e, partially  divided by a partition.   Nor is  this all
the possible  mischief; for it is not uncommon for the  ossa  nasi to
suffer, and, in some instances, the superior maxillary  bones.
   All the varieties of lupus are rare after the  age of forty.  The
disease is more common  between the ages of six  and sixteen than
at earlier or  later  periods.  The female sex is more subject to it
than the male.  The superficial lupus is frequently considered  as a
scrofulous disease.
  * Abrege Pratique des Maladies de la Peau, d'apras les Auteurs leg plus estimes,
et surtout d'apras les Documens pri? dnus la Clinique, de M. le Dr. Biett, par MM.
Cazenave et Schedel. 
DISEASES ABOUT THE FACE.
107
  In the treatment, general as well as local means are, for the most
part, proper.  If the  patient be manifestly scrofulous, and the lupus
superficial, the medicines and  regimen in repute for this state of the
system should be employed.   In such cases, the use  of iodine lo-
tions, made in the manner directed  by Lugol, were found  by Dr.
Houghton to  produce striking amendment.   The proto-ioduret of
iodine, in the dose of quarter of a grain twice a day,  is one of the
best preparations for internal use.   Iodine, however, is only useful
in the superficial variety of  lupus.  The chloride of barytes, which
was believed by Bateman to have influence in dispersing the tuber-
cular formation, is not at  present so frequently prescribed as the
chloride of lime, which agrees better with the stomach.
   The  tinctura ferri  sesqui-chloridi,  and the sesqui-oxide of iron
were formerly praised as useful medicines in cases of lupus; but I
am  not  aware  of their possessing  any  specific power  over  this
disease.
  Arsenic has considerable  influence in checking the progress of the
tubercles, and altering the character of the ulcerated surface.  Small
doses of the  liq. arsenicalis  may be  prescribed, beginning with not
more than two or  three drops thrice a day;  but gradually increasing
the dose to ten, if  no deleterious effects are produced.
   Another medicine  in repute is the bichloride of mercury, pre-
scribed in minute  doses, so as gently  to affect the gums.
   External  applications constitute  the most important  means of
cure.   Sometimes the progress of the lupoid  tubercle may be ar-
rested,  and  ulceration prevented by  the  application of leeches to
the inflamed skin round its  base, followed  by evaporating  lotions,
and alterative doses  of calomel.  Thus  the disease may often  be
reduced to a chronic  state, in which  friction with ointment of the
ioduret  of zinc, or mercury,  may be employed  to promote its ab-
sorption.   Biett uses the ioduret of sulphur, made into an ointment,
in the proportion  of fifteen  grains to  an ounce  of simple ointment.
in  the hypertrophic lupus, these resolvent ointments are particularly
indicated.   When the tubercles are once ulcerated, the  ung. hydrarg.
nitratis, or the liquor  arsenicalis, is often used; but generally eschar-
otics now become  necessary, and arsenic is the substance frequent-
ly preferred.   Sir Astley Cooper uses an ointment composed of Sj.
of  spermaceti cerate,  5j.  of sulphur, and  3j.  of white  arsenic.
When  the  action  of arsenic is impeded by the thickness of the
cuticle  over indolent  tubercles, a small blister is  sometimes  first put
on  the part, or the  following ointment  applied: R ung.'cetacei Sss.,
oxydi arsenici 3j., empl. cantharidis 5iij.; M. ft. ung.  Sometimes
an  arsenical paste  is  applied.   That  of Frere  Come is  made  by
moistening  arsenic, cinnabar, and  burnt leather.   Being a  very
powerful application, this paste demands particular caution not to let
it act on more than a small  area, lest the  patient be poisoned by it.
Indeed, no arsenical  dressing should  be allowed  to come in contact 
108
DISEASES ABOUT  THE FACE.
with a surface of greater extent than a shilling.   The above paste
is apt to bring on erysipelas of the face.   A milder, safer, and bet-
ter arsenical  paste is that recommended by  Dupuytren, composed
of calomel and oxyde of arsenic, moistened with mucilage in the
proportion of from six to  twelve  parts  of arsenic in every 100.
The same eminent surgeon also used an arsenical  powder, made of
ninety-six parts  of calomel  and  four of arsenic   These applica-
tions, however, he applied but to a small surface  at a time.   The
nitrate of  silver, sulphate of copper, and  muriate  of antimony, are
likewise escharotics in  great  repute; and so is  the  concentrated
nitric acid for cases where the ulceration invades the deep layers of
the  skin  and the cellular  tissue.   At the  Hopital  St.  Louis, a
solution of 3j. of the protonitrate of mercury in an ounce of nitric
acid is  employed with great success, by Richerand and Cloquet.
  I  have  known lupus cured by excision of the diseased part of
the skin.
  When the nose has been destroyed, a new one has often been
successfully formed from the skin of the forehead.*

                    LIPOMA  OF THE NOSE.

  The  integuments of the apex and alae of the nose are sometimes
enormously thickened by interstitial deposit, so that  a true hyper-
trophy of them  is occasioned,  forming, as  Mr.  Liston  correctly
states, a lobulated reddish-blue mass, intersected by fissures.f   The
sebaceous follicles are so expanded,  that they will  admit  the  point
of a quill.   The ramifications of many turgid superficial veins are
seen on the part.   The disease, besides being productive of vast
deformity, may attain such magnitude that vison, the passage  of  air
though  the nostrils,  and the  introduction of food into the mouth, are
more or less obstructed.
   The only mode of relief is that of removing the hypertrophied
skin.  If both sides  of the nose are affected, the nostrils may  be
distended with lint, and then a perpendicular incision made through
the morbid skin, in the mesial line of the nose.   The edge of the
divided integument may then be taken hold of with  a pair of for-
ceps, and the diseased structure carefully cut away.   The bleeding
is generally copious.:  some of the vessels will require ligature; the
others will cease to bleed on  pressure being applied.

                      POLYPI OF THE  NOSE

Are swellings arising  from  the mucous membrane of  the nose, and
P:ctealMedS0;eght0n,S Ar,iC'e °" "N0H me Tan*e'e'"  * *e  Cyclopia of
 t Elements of Surgery, part ii. p. 179. 
                    POLYPI OF  THE NOSE.                 109

generally consisting of a soft substance easily  torn, streaked  with a
few vessels, and of a light yellowish or grey color, and not endued
with much sensibility.   The disease is most common in persons be-
tween forty and fifty, though occasionally met with  in younger sub-
jects.   The polypi, which have the character now enumerated, are
not of a malignant nature; and whatever inconvenience may be pro-
duced by  them is caused by their obstructing the nostril, and by their
pressure on the adjacent parts.   They are commonly of a puriform
shape, though,  if they are large, their figure is in a great measure de-
termined  by that of the  cavity  in  which they  grow; but whatever
may be their shape, they are  invariably connected to  the mucous
membrane by  a narrow stalk or pedicle, sometimes termed their root.
They rarely or never grow from the septum nasi, but usually from a
point at or near the upper os spongiosum.
   The polypi, whose texture corresponds to what I have mentioned,
are those  mostly met with, and  often named soft or gelatinous po-
lypi; or occasionally mucous polypi, from their structure  bearing a
considerable resemblance to the mucous membrane from which they
originate;  or  benign polypi, in consequence of their having no dis-
positon to assume  a dangerous morbid action.    Sometimes they are
of a firmer consistence and  fibrous texture, when  they are termed
fleshy polypi;  but  these are more  frequently  noticed  in the uterus
than in the cavity  of the nose, and grow not  from the lining of the
uterus, but under  it, in, or connected  with,  the  substance of the
womb itself.   Another  kind of disease is improperly called the ma-
lignant polypus, because it  is not truly a polypous excrescence at
all, but a  tumor, partaking  in every respect of the  nature of medul-
lary cancer.
   In many cases,  several polypi  of different sizes occur  in one or
both nostrils.   Sometimes we meet with only one; and, in particular
examples, the nostrils are filled  with a peculiar kind of polypi, con-
sisting  of cysts or vesicles, filled  with  a colorless  fluid:  these are
vesicular or hydatid polypi,  as they are  termed, and are not uncom-
mon in children and very young persons.
   Truly cancerous polypi  are said, occasionally, to take place  in
elderly persons; but the malignant polypi, which I  have seen, were
evidently  specimens of  medullary sarcoma.
   The common pendulous  soft benign kind of polypus  generally
grows from the external  side of the cavity of the nose,  and, in many
examples, from the mucous membrane covering the ossa spongiosa.
The growth of a polypus from the septum narium,  if it ever  occur
at all, is  so uncommon, that some surgeons of the most extensive
practice have  never seen an instance of it.  The commencement of
the disease is attended with  a feeling of obstruction in the nose, like
what is usually felt in  an ordinary  catarrh, the obstruction  being
more considerable in wet, than dry weather.   These polypi, when
under a certain size, may be made to advance or recede by the force
   vol. n.                 10 
110
DISEASES ABOUT  THE  FACE.
 of the breath in inspiration and expiration.   The sound of the voice
 is nasal, and there is generally some uneasiness  felt about the fron-
 tal sinuses.
   Sometimes, when a polypus becomes large, it passes towards the
■ velum pendulum palati, over which a  part of it hangs  towards  the
 pharynx; or if it originate towards the  back of the nares, it may
 take the same direction, instead of towards the nostril.   In certain
 examples, polypi project in both  directions.
   Common  polypi  cannot be cured  by local applications; caustic
 only acts upon their surface, and  cannot get to their root.   They
 grow indeed faster than any caustic can destroy  them.
   Extraction, excision, and the ligature are the  three means of cur-
 ing nasal  polypi.   Extraction is  the method usually  preferred  in
 this country, and is accomplished with forceps made for  the purpose,
 and of different shapes and  sizes.  Some are slightly  curved, and
 formed with oval excavations on the inside of the ends of the blades,
 and also with an aperture in each of them.  Others are straight,
 and the inner surfaces of the  blade furnished with projections,  or
 teeth.    Some  are  constructed with  serated  blades, which,  when
 shut,  meet in the manner of a suture of the cranium.
   The patient being seated opposite a strong light, the  surgeon first
 examines the extent and situation of the polypus with a probe, en-
 deavoring  in particular to make out the  point of its attachment and
 the place  of the  pedicle.   This cannot always  be done; but we
 know that the os spongiosum superius, and the outer and upper side
 of the nostril, are the common situations for the attachment of the
 polypus.   We therefore convey the forceps in  that  direction, and
 endeavor to seize the  pedicle.   If we  succeed thus far, the best
 plan is  not to pull it directly outwards by a jerk,  but  to twist the
 tumor from its connection.  The haemorrhage from soft benign po-
 lypi is  never dangerous, though it  may be  copious.   Sometimes, a
 layer of bone comes away  with the  polypus, a circumstance often
 regarded as favorable,  inasmuch as the root of  the tumor will  then
 have  been taken away.   After the operation, the nostril  and  nares
 should  be washed occasionally with an astringent  lotion, containing
 alum, or the muriate of ammonia.
   When a polypus projects backward, towards the throat, it is some-
 times taken hold of with a pair of  curved forceps,  introduced from
 the mouth, and extracted.   But  frequently another part extends
 forwards, which we  may begin with.   In this manner, the pedicle is
 sometimes broken, and both portions may then be readily extracted.
 Much  of  the  operation  is necessarily  performed, as  it were,  in
 the dark;  for,  after the bleeding begins, nothing  can  be  seen.
 Supposing only a fragment of the  polypus to be at first taken out^
 we should not stop,  but try to extract the  rest,  either piecemeal  or
 in one mass, just as  may be practicable.
   Excision is a plan occasionally  applied to large polypi extending 
SALIVARY  FISTULA.
Ill
back  towards the throat,  and having a  pedicle, the situation of
which can be felt and reached with a pair of long probe-pointed scis-
sors.   The bleeding need not he feared; but,  so far as my expe-
rience goes, we  seldom know the precise situation of  the  pedicle,
or can reach it sufficiently well with scissors to  make  this method
advisable.
   The  ligature  has  also been applied  to similar polypi extending
towards  the throat.   The noose of a ligature, or piece of wire, is
introduced through the  nostril to  the back of the throat,  where it
is put over the tumor with the aid of a pair of forceps.  The ends
of  the  ligature,  or wire,  hanging out  of the  nostril,  are then
passed through a double cannula and twisted.   It is a practice rare-
ly adopted in this country.  The best instruments for this operation
are those of Graefe, which may be procured of Weiss.
   Vesicular or  hydated  polypi  generally grow again.   We may
clear the nostril  from them, but  they  return.   One plan,  to which
they will sometimes yield, is that of applying strong  astringent lo-
tions  to them.   They  should be first removed, and the lotion then
applied by means of lint.
   With respect  to the malignant kinds of polypi,  they are out of
the power of surgery; all that can be  done is to lessen the patient's
sufferings by narcotic medicines, opium, hyoscyamus, or  hemlock,
and to diminish the foetor  of the discharge by means  of lotions, con-
taining the chloride of soda, or lime, or a proportion of creosote.

                       SALIVARY  FISTULA.

   An opening in the cheek, from which the saliva escapes,  arising
from  a wound, ulceration, or phagedenic  disease, involving the paro-
tid gland or duct, is called a salivary fistula.   The  duct  has  also
been  burst by  violent  blows.   We sometimes  meet with  cases, in
which the  parotid duct becomes obstructed by a calculous  forma-
tion within it, just in the  same way as the salivary ducts under the
tongue  become  occasionally  blocked up with  calculous matter.
Calculi in the parotid duct, if  not removed, may, of course, enlarge,
and excite inflammation and an abscess in the cheek.  This bursts,
and the flow- of saliva from the opening immediately  draws the sur-
geon's attention  to the state of the parotid duct; a  probe  is intro-
duced, and the calculus felt.   Here the  first indication is to extract
the extraneous substance, and then endeavor to heal the  ulcerated
opening in the cheek.
   If  the parotid  duct is recently wounded, the  sides of the  wound
should be brought together, and pressure applied.  Thus a salivary
fistula may often  be  prevented altogether:  either the divided ends
of  the  duct re-uniting, and the saliva resuming its original course,
or, what  is more probable, the wound in the face healing at every
part,  with the exception of a small fistulous track, which serves as 
112
DISEASES ABOUT  THE  FACE.
a continuation of the  duct into the cavity  of the mouth.   This is
supposing the wound to have extended quite through the cheek.
   When a  salivary fistula is  already formed, it may be cured  by-
passing a seton from the fistulous  opening into the  mouth, keeping
it there a certain time, and, after withdrawing it, applying the nitrate
of silver to  heal the  outer opening.   The  caustic  alone will fre-
quently succeed.  Another ingenious plan is that of Boclard, who
passed a leaden  style into  the orifice of the portion of parotid duct
connected with the gland,  and then united the outer wound  with the
twisted suture.   This is a quicker  mode  of cure than  the seton,
and  more sure than simply closing  a recent wound and applying
pressure.

                  DISEASES OF  THE  ANTRUM.

   The antrum, or rather its mucous lining, is subject to inflamma-
tion and suppuration.   A  darting  pain is felt in the side of the face,
usually supposed to be the toothache, and, indeed, mostly connected
with a carious state of the neighboring teeth.  If an abscess form,
and the matter be prevented from passing into the nose by acciden-
tal obstruction, it may  produce an expansion and attenuation of the
sides of the antrum; and  at length  discharge itself either  through
the cheek, or, what is more common, into the mouth.
   The indications are, to  lessen  inflammation and pain by antiphlo-
gistic soothing means; to  provide a  speedy outlet  for the  matter,
when an abscess forms; to check  the discharge, and maintain clean-
liness by the use of tepid slightly astringent  injections; and, if there
should be any dead bone or carious teeth present,  to remove them
as soon as circumstances will allow; the teeth as soon as the inflam-
mation has somewhat abated, and the  dead bone when  exfoliation
is sufficiently advanced.
   When there is a carious tooth  below the antrum, its extraction,
and  the  perforation of the  socket, are  sometimes considered  the
best  mode of  making an outlet for the matter.  In other cases, the
third  or fourth grinder may be drawn  and  the socket  perforated.
Another method is that of detaching the cheek  from the front sur-
face  of the antrum, and applying a small trephine, or other perforat-
ing instrument, to the bone.   The cheek is to be raised up so as to
expose the membrane covering the gum on  the side of the face, and
a transverse incision  made  down to the bone.   The  instrument,
preferred by Sir Benjamin Brodie for the  perforation of the bone,
is a  pair of  sharp-pointed  strong scissors.  This  plan is applicable
to cases in which the socket is filled up  with bone.
   In  one case  of inflammation  of  the  antrum,  recorded by  Sir
Benjamin Brodie, where the severity  of the symptoms made him
suspect the presence of matter in that cavity, he made a perforation,
but no pus was met with.   Two grains  of calomel and half a grain 
DISEASES OF THE ANTRUM.
113
of opium were then given three times a day, and, on the gums be-
coming sore, a cure speedily ensued.

           COLLECTION OF MUCUS  IN THE ANTRUM

Is more  rare  than one of puriform fluid.   The  cause of such an
accumulation  is probably an accidental obstruction of the  natural
communication of the  antrum with the nostril, between the two tur-
binated bones.  The  manifest -judication is, to make an outlet  for
the confined  fluid, which is  producing the swelling and  pain of this
part of the face.   In one interesting case, related  by Sir B. Brodie,
he made an  opening  with a knife in  the  swelling above  the gum,
which opening continued ten years afterwards, the patient  wearing
a plug in it.

            MEDULLARY DISEASES  OF  THE ANTRUM

Produces a gradual expansion of it, and then such pressure on other
parts as  leads to an immense degree of suffering and often fatal con-
sequences.   Thus, the pressure may  render the eye  amaurotic, or
even displace it from the socket; it may force out all the neighboring
teeth; make  its way through the palate and alveolary process into
the mouth; fill up the  nostril; protrude through the  integuments of
the face  in a  frightful  form; or through the cribriform plate of the
ethmoid  bone, or the orbital process   of the frontal bone into the
cranium  itself, when the patient soon dies in a comatose state.  I
have seen one case, however, in  which the patient did not die, or
even become senseless, till the mass of the tumor in the cranium had
attained the size of an  orange.
  When the character of the disease  is known beforehand, and es-
pecially  when the soft  parts  are implicated, an operation is not like-
ly to be  of any service, the disease almost always returning.   How-
ever, if the new growth were entirely  restricted to the antrum, and
the patient, after a candid explanation of  the nature of the disease,
and the bad chance of benefit from an  operation, were anxious to
take that chance, the surgeon would be justified in performing the ex-
cision of the  upper jaw.  This is to be preferred to the plan of open-
ing  the antrum, and attacking the disease in that situation, as Desault
appears sometimes to have done.   I do not, at the present time, re-
collect how  far the cases published by  Desault amount to a satisfac-
tory proof  of the permanency of the cures;  but, in one example re-
corded by  Dr. Anderson of Glasgow, no recurrence  of disease in
the  antrum had taken place five years  and a half after the operation,
as was ascertained by a post mortem examination.   The actual cau-
tery had  been employed after the knife had done its duty; a measure
very essential for the prevention of a  relapse.   However, I should
be sorry  to advocate the removal of medullary tumors from the an-
                         10* 
114
DISEASES ABOUT  THE  FACE.
trum.   No doubt, the disease in this situation presents little chance
of benefit  from such or  any  other proceeding; but fibrous tumors
hold forth more prospect of permanent success.

                             HARE-LIP

Is for the most part  a congenital malformation; but it  is  now and
then produced by accidental wounds.   It is mostly met with in the
upper lip, and very seldom in the lower.   Sometimes there is only
one fissure; on other occasions too, the hare-lip being then termed a
double one.  In some cases, the fissure only extends partly towards
the nostril; in others, it reaches into  that aperture, which  is then
much expanded.  The  fissure is of course  to one side of the me-
sial line; and its edges,  which are covered by a continuation of the
prolabium, a^re  rounded  off below.  Besides the fissure  in  the lip,
there is frequently so large a cleft in the upper jaw and palate bones,
as to convert the mouth and  cose, as  it  were, into one  cavity.  A
double hare-lip is particularly  often accompanied  by a fissure in the
bones of the palate.   Someumes, but not usually, there is a fissure
in the soft palate.   In certain examples the jaw bone, or teeth, pro-
ject forward into the cleft of  the lip.
  A hare-lip, besides being a great deformity, is  attended with a
defect in the speech;  and when the fissure extends through the pa-
late, there is more or less impediment to sucking and swallowing.
  In ordinary cases,  the cure is easy;  the surgeon  pares off the
margin of the fissure, brings the fresh cut surfaces into contact, and
keeps them in this position until they  have grown together.
  As infants are very subject to convulsions after operations, many-
surgeons think it best to defer the cure of a hare-lip till the child  is
about two years of age, or even rather older.   The youngest sub-
ject on which I ever operated, was only five  months old,  but the
case was perfectly successful.
  In the operation, the wound  should be as clean and regular a cut as
possible, in order that it may the more certainly unite by adhesion,
and of such a shape  that the  cicatrix may form  one narrow  line.
The margins of the fissure, therefore, ought not  to be cut off with
common scissors, which always produce some degree of contusion;
though what are called knife-scissors,  which are employed  by some
operators, are said' to answer well.
  Sometimes a bit of pasteboard is placed under the lip; and while
this is supported and fixed upon  it, the edge of the fissure is cut off
with a sharp bistoury.  Or the lip may  be held with a pair of hare-
lip forceps, in such a manner that as much of the edge of the fissure
as is to be removed, is situated at the  side of the upper blade of the
forceps, so that it can  be cut  off with  one  sweep  of the knife
which will be guided along the instrument, as along  a ruler.   This
is to be done on each side of the cleft,  the  two incisions meeting 
                           HARE-LIP.                       115

at an angle above, thus A, in ordenthat the whole of the wound may
admit of being brought together, and  united by the first  intention.
Particular care should be taken to remove completely the rounded
corners at the lower part of  the fissure;  for if this  be not done,  an
unseemly notch is left  in the  prolabium.  Mr. Liston's mode of
operating I commonly prefer  to  any other, as  being the neatest,
quickest, and  most easily  accomplished: it consists  in  passing a
straight bistoury from without inwards, so as to  penetrate  the mem-
brane of the mouth, above  the angle of the fissure.   The  part is
stretched by the fingers of an assistant, whilst the instrument is car-
ried downwards, so  as to detach the edge and rounded corner of the
fissure.  A similar proceeding  is then adopted  on  the other side.
Hemorrhage is prevented by the  assistant making gentle pressure
whilst the surgeon stitches the lip.
   As the lips are exceedingly moveable, and it is essential  to heal
the wound by adhesion, the twisted  suture  is generally  employed
for keeping its surfaces in contact.   Two steel  pins, or silver pins
made with steel points, are introduced through its edges, and  a piece
of thread is then repeatedly twisted round the edge of the pins, from
one side of the division to the other, first transversely, then oblique-
ly, from the right or left end of one  pin  above, to  the end of the
lower on the opposite side,  &c.   Thus  the thread, being made  to
cross as many  points of the  wound as possible,  maintains the edges
in contact.   If silver pins are used, the points which are  made  to
slide on or  off the instruments, are now removed; or  if steel pins
are employed, the points are taken off' with  a small  pair  of  cutting
forceps.  A great deal of exactness is requisite in the introduction
of the pins,  in order that the edges of the incision may afterwards
meet correctly: and, as it is  of great consequence to make the red
parts of the lip correspond precisely,  this object  is secured  by
introducing  the lower pin first.  The  pins  ought  never  to  extend
more deeply than about two-thirds through the substance  of the lip;
and they should be  removed in three or four days, the support of
sticking plaster being then sufficient.
   When the case is a double hare-lip, and  the  intervening portion
of skin is sufficiently broad  and long, it should be  preserved  in the
operation;  but if narrow and short, it should be cut away.   In the
latter event, the rest of the operation is the same as  for  the single
hare-lip.  But, when  the  middle piece  of skin is  to be saved, a
union between  it and the lip  on one side is first to  be accomplished
l)y an operation like that for the single hare-lip, and then, in a few
weeks, a second operation of the same description  is to be perform-
ed on the opposite side.
   Hare-lips are frequently complicated with  a fissure in the roof  of
the mouth.   When  it is confined to the  upper  maxillary  bones,  it
generally closes, by slow degrees, after  the operation-x but when it 
116
DISEASES- ABOUT  THE
FACE.
reaches along the palate  bones and velum pendulum  palati,  its en-
tire closure  rarely or  never takes  place.   Sometimes  one upper
maxillary bone exceeds the level of the other.   When  the  hare-lip
is double, a  distinct part of the jaw may push  forward  the middle
portion of the skin.   In certain cases, one of the maxillary bones
incline backwards, and its alveolary  process juts out.   In other
examples, an impediment to the union of the hare-lip arises from the
projection of a tooth, which must then be extracted.
  When the jaw itself projects, the  common  preliminary  step to
the operation for the hare-lip consists in  cutting away the bony
prominence.   But, according to Desault,  this  measure is  seldom
proper; for  when the  original congenital  deformity  is  removed, a
disfigurement of the face yet follows, from the  upper lip having no
proper support.   The diameter  of the upper jaw is also liable to
diminish so considerably, in proportion  as the two maxillary bones
coalesce, that the upper and lower jaws no longer correspond,  and
the same kind of inconvenient mastication is  produced, which is
often  noticed in  old  people.   Hence, Desault  preferred reducing
the projection of the jaw, by means of  the pressure of  a tight ban-
dage; for, as there is a fissure in the roof of the mouth,  the  bony
prominence  has little support, and readily yields.   In one instance,
I made the necessary pressure with a small spring truss, which, in
a few weeks  reduced the bony projection sufficiently to  let the ope-
ration be undertaken.  In  another  instance lately brought to  me
from the country, I advised the same plan to be tried.
  [Surgeons  sometimes fail in obtaining complete success, in  their
operations for hare-lip,  by cutting the edges into an improper  shape-
It matters but little, whether the knife or scissors  be employed, if they
only be sharp. The edges after being pared, should  be concave.  A
fine cambric needle should be used,  to support the lower margin in
nice coaptation, and the interrupted suture or  sutures for the  remain-
der of the fissure.  It is obvious,  that  if the margin be convex, then
the prostomeon cannot  be brought into perfect adjunction.—Ed.]

                    CANCER  OF THE  LIPS.

   The lips are  frequently  the  seat  of troublesome  and  obstinate
ulcerations,  sometimes connected with disorder of the general health,
but more commonly prevented from healing by  the constant motion
and friction  to which they are subjected.
   Some ulcers  of the  lip  having  a foul, and even a  malignant ap-
p-arance, will yield  to liquor arsenicalis, iodine, the iodide of po-
tassium,  the extract of hemlock, the  compound  decoct,  sarsap.,
or the compound calomel  pill,  with  occasional  purgatives.  The
most  eligible dressings are  generally the  ointment of the "nitrate
of mercury,  or  that of the nitrate of silver, 10 grs. to announce.
In one case in University College Hospital, I tried both the carbo- 
DISEASES OF  PARTS  IN THE MOUTH.          117
nate of iron and Dupuytren's arsenical powder, and found the latter
answer better than the former.
  When cancer takes place, it  is almost always in the lower lip;
and it is not an uncommon opinion, that the  pressure and irritation
of tobacco pipes give a disposition to the disease,  which  usually
commences as a small  tumor in the cellular tissue between the  mu-
cous membrane and the skin.  The  swelling and induration make
the disease obvious  before  the  villous surface  of  the lip cracks
transversely, and a thin fluid oozes out.  The part  then ulcerates
and scabs by  turns,  and the disease  ultimately penetrates more
deeply, and throws out a  fungus.  The patient  is generally a male
subject, above the middle age, and, as  I have said, accustomed to
smoking.  The skin, mucous membrane, and  labial glands  now
form a close compact mass, and  the  submaxillary lymphatic glands
become  affected.
   Whenever any malignant  disease  of the  lips resists  alterative
plans, it should be extirpated with the knife, before its effects ex-
tend to the lymphatic glands.  The disease may be  removed by an
operation resembling that for the cure of hare-lip, or  by a simi-lunar
incision through the lower lip, as practised by Dupuytren, by which
a freer removal of the part may be made than  can  be effected in
the other way.   The commissures of the lips, however, should al-
ways be spared.   A moderate breadth of the lip may thus  be taken
away with much less deformity than might be apprehended.

             DISEASES  OF PARTS IN  THE  MOUTH.

   irounds of the tongue are generally transverse, and caused by the
violent and spasmodic closure of the  teeth, while the tongue is out
of the mouth, as sometimes  happens  in  epilepsy, and falls on the
the chin.  Wounds of the tongue, thus produced, may gi\e rise to
profuse hemorrhage ;  such as would  prove fatal if  not soon  sup-
pressed.  As for taking up one of the lingual arteries for this  pur-
pose, it would not generally answer, because  the wound almost al-
ways  affects the branches  of  both.  Sometimes, in order to  stop
the hemorrhage, the surgeon has  been  compelled to apply the ac-
tual cautery, or even to pass  a double ligature through the centre
of the tongue, behind the wound,  and then tie  each side of the or-
gan.   With the aid of a tenaculum forceps,  however, the tongue
may be kept steady, and drawn sufficiently forwards to facilitate the
application of the  ligature to any bleeding  vessel.   This  plan is
always the most eligible, when practicable.

INFLAMMATION AND  PRODIGIOUS SWELLING  OF  THE  TONGUE.

  The tongue,  when in the state  of inflammation, mcy swell so en-
ormously  as  entirely to fill the cavity of the mouth,  protrude  be- 
118
DISEASES ABOUT  THE  FACE.
 tween the teeth, and obstruct deglutition.and respiration  in a most
 dangerous degree.  I remember a soldier's wife at Brussels, whose
 life was in urgent danger  from such  an affection of the tongue,
 brought on by the use  of mercury.
   Common antiphlogistic treatment will not afford sufficiently prompt
 relief.  The right practice consists in making two or  three longitu-
 dinal  incisions in the dorsum of the tongue.   The copious bleeding,
 which ensues, soon reduces the swelling.   In bad cases, all medi-
 cines and food ought to be given  through an elastic gum tube, in-
 troduced down the pharynx from  the nostril.

         ULCERS  AND  INDURATIONS OF  THE TONGUE.

   Putting out of consideration the effect of mercury, the irritation
 of carious  teeth, with points  and inequalities,  is one  of the most
 frequent  causes of  ulceration of the tongue.   Here, it is  clear
 enough, that  the right treatment consists  in extracting such teeth, or
 Gling  away their sharp projections.
   Hard tubercles  sometimes grow on the dorsum of the tongue,
 having a  narrow pedicle, and a broad mushroom-like head.   These
 may be snipped  off with a  pair of scissors, or tied, and the parts
 afterwards  touched with the nitrate of silver.
   I have seen the whole surface  of the tongue  covered with hard
 tubercles, some  of them in a state of ulceration.  On this form of
 disease, I find that mercury has considerable effect.   Some invet-
 erate  ulcerations of the tongue may be cured by the same alterative
 plans, as I have advised for similar sores on the  lips.  Venereal ones
 1 have noticed with the subject of syphilis.

                  CANCER  OF THE  TONGUE

 Commonly begins as an irregular, rugged, unyielding knob, gen-
 erally situated in  the anterior third of this organ, midway between
 its raphe and its edge,  the mucous surface being puckered and  rig-
 id, and the patient experiencing  severe  pains  in  the  part,  which
shoot towards the ear.   Sometimes the knob acquires considerable
 size before ulceration commences.  Persons, about the age of for-
 ty, are most subject  to cancerous  disease  of the tongue.   The
glands of the neck after a time become swollen and indurated, and
 profuse bleedings are  disposed to  take place  from time to time,
whereby the patient becomes extremely weakened  and  reduced.
  There are  two methods of extirpating  cancerous  portions of the
tongue: one  by  the knife:  the other by a double ligature  passed
through the centre of the part by  means of a sharp-pointed  curved
needle fixed in a  handle, one  portion of the ligature being  firmly-
tied over one side  of the organ, and the other portion over the oth-
er side.  In this operation, some  surgeons  first take  hold  of the 
             DISEASES  OF PARTS IN  THE  MOUTH.          119

 tongue with a pair of hook forceps, so as to fix it.   The objection
 to the knife is the hemorrhage, which, if profuse, and  not capable
 of being stopped by the methods noticed in the remarks on wounds
 of the tongue,  would require some extraordinary means for its sup-
 pression,  such as the  application of the  actual  cautery, or  even
 securing the lingual artery as it passes over the cornu of the os hy-
 oides.  When the extirpation of a cancerous  induration can be ac-
 complished by removing a piece of this organ in the shape of the
 letter V,  the best mode of stopping  the bleeding  is to  bring the
 sides of the wound closely  together with a suture.  The tongue
 may also  be removed by an incision,  made under the jaw, between
 its symphysis and the  hyoid  bone.   If the portion to be removed
 be drawn out through the wound, and  the rest held with a tenacu-
 lum,  the requisite incision may be performed,  and  the arteries tied.
 fn this way, also, the extirpation with a  ligature may be performed
 further back, than in the common mode.*
   Relapses are frequent after  operations on cancerous  tongues;  a
 fact that should make us cautious in the judgment we give, respect-
 ing the chances of a cure.

         OF  DIVIDING  THE  FRjENUM OF THE TONGUE.

   Children are not so frequently tongue-tied as nurses and mothers
 imagine;  and we may  be sure, that when once an infant  has  been
 able to suck properly, whatever may  be its present  inability to do
 so, it does not  procedd  from the confinement   of the tongue  by the
 frasnum, but probably from the  large size of the nipple,  excoriation
 of the lips, or  other causes, which should be investigated.
  When the frsenum really ties the tongue too  closely to the bottom
 of the mouth, the surgeon will find, that  he cannot raise the  tongue
 to the palate with his fingers.    Sometimes, however, the fraenum is
 really so short  that it interferes with the requisite movements of that
 organ in  sucking, deglutition, and  the  articulation of words.   The
 surgeon is  then called upon to divide  it, which may be done with  a
 pair of blunt-pointed scissors, care being taken to direct the incision
 downwards, so as not to injure the raninal vessels.
  An immoderate cut gives  rise  to  two dangers:  one is, that  of
 hemorrhage; the  other, that of the tongue being left so unfixed, that
 it may be thrown back into the pharynx  in the act  of deglutition,
 and cause suffocation.   A similar danger has been exemplified after
 the operation of removing the lower jaw.
  With respect  to  hemorrhage, children  are constantly disposed
to suck and swallow whatever comes  into their mouths, and  hence
 they sometimes die with their stomachs  full  of blood, even when
* Arnott, Med. Chir. Trans, vol. xxii. p. 20. 
120
DISEASES ABOUT THE FACE.
only the branches of the raninal artery are wounded, and  not  the
trunk itself.   Nay,  it is  alleged, that the veins have  sometimes
yielded a dangerous quantity of blood, which has been swallowed.

                            RANULA

Is a tumor situated under the tongue, and  commonly believed  to
arise  from a  dilatation  of the  duct of the submaxillary  salivary
gland.  The swelling is  usually  situated on one side of the fraenum,
and, when large,  extends forwards,  under the apex of the tongue.
Its contents are generally a  glairy fluid,  resembling white of egg;
but if the tumor  has been of long standing, their consistence may
be much thicker, and even blended with calcareous matter.   Neg-
lected ranulae may attain  a considerable size, and not only obstruct
the movement of the tongue, but even  produce  serious  annoyance
and mischief to the teeth and  lower jawbone by their  pressure.
In general, however, when they have become as large as a walnut,
they burst; the opening heals up; and then they fill and burst again.
   Some ranuke arise from obstruction of the duct, the orifice of which,
therefore, should be examined; and if a piece of calculus can be  felt
with a probe, it should be removed:  this alone would lead to a cure.
In ordinary cases, the disease may be cured by opening the swell-
ing and snipping off a portion of the sac,  so as to prevent the part
from closing again.   Merely opening the cyst, without the excision of
a portion of it, will not always suffice.   It is also a good plan to apply
a bit of lint, dipped in a weak solution of lunar caustic, to its inner sur-
face.  I lately attended a young lady for a ranula, that would not yield
to any ordinary modes of treatment.  I opened it, and removed a con-
siderable piece of ihe cyst, filling the cavity with lint;  but this plan
failed.  I then  cut  away a second piece of the cyst, and  dressed
the cavity with lint dipped in a solution of nitrate of silver: this also
was followed by a relapse.   I then passed a seton through the ranu-
la, and kept it  applied for two or three weeks in  vain.   Lastly, I
made a small opening,  and put into it a little silver tube,  which was
worn  about five or six weeks, and the disease never returned.  The
latter treatment of ranula by puncturing it, and  placing in the open-
ing a  small tube not  quite half an inch long, and made  with a rim,
by  which  it is  retained  in  the  part, was  frequently adopted  by
Dupuytren.

                  DISEASES  OF  THE TONSILS.

   When the tonsils  are so considerably swollen from  an attack of
acute inflammation that deglutition and respiration are seriously  ob-
structed, they should be  freely scarified;  after which, the bleeding
from them, assisted by venesection, leeches, and other antiphlogis-
tic means, will  in general quickly bring down the enlargement. 
             DISEASES OF PARTS IN  THE  MOUTH.          121

  If the same  inconvenience should arise from  the  formation of
matter,  the abscess should  be opened with the long narrow sharp-
pointed  bistoury, the blade of which  may be  partly covered with
lint to keep the edge from wounding the tongue.
  The tonsils are also liable to chronic enlargement, more especially
in scrofulous  subjects.   It is a mere hypertrophy, without  any ten-
dency to cancerous or malignant action.   The  tonsils may, indeed,
swell to such a  magnitude as to close the aperture  between the
mouth and pharynx, and create a total  impediment to swallowing,
and much difficulty of breathing.
   If these enlargements resist the internal use  of iodine,  or  small
doses of the bichloride of mercury, with  tinct. rhei,  or tinct. cin-
chon, and  the application of lunar caustic, or  nitric acid,  the ton-
sils, or rather the redundant portion of  them, should be extirpated
by means of a ligature or cutting instrument.   Cheselden's plan  of
passing a ligature through a diseased tonsil, by means  of a crooked
needle  fixed  in a handle, and  with an eye near its  point, is  not a
bad method.  Graefe  has also invented a most ingenious instrument
for the purpose.  Excision  of  part of the tonsil, however, is  a
better  practice,  and  may be  safely  performed  with  a hook and
straight probe-pointed bistoury, for the hemorrhage will never be
serious, if the knife be directed downwards and inwards away from
the carotid artery.
    [The instrument best adapted for the  removal of the tonsils when
 enlarged, is one invented by Mr. George Tiemann, an ingenious sur-
 gical instrument  maker, of the city of New-York.—En.]

                  ELONGATION OF  THE UVULA.

    The uvula is sometimes thickened and considerably elongated,
 producing great uneasiness about the throat,  and  irritation  of the
epiglottis.   If the disease cannot be remedied  by astringent gargles,
or  touching the uvula with the tincture of the sesquichloride of iron,
the best plan is to snip off the superfluous length of the part  with a
 pair of long blunt-pointed scissors.   I  once attended  a gentleman
 with a  phagedenic venereal sore  throat, whose uvula was so deeply
attacked at  its  root with the same kind of ulceration, that  it re-
 mained attached only  by a  few fibres, so as to hang down, and irri-
 tate the eppiglottis in a  most distressing manner.   Under  these
 circumstances, as it could  not be saved, I immediately cut it off, to
 the great relief  of the patient.

                    DISEASES OF THE GUMS.

    The gums in the natural and healthystate  are not very  sensible:
they may  be divided with a lancet without  much pain; and the
    vol. n.                    11 
122
DISEASES ABOUT  THE  FACE.
 pressure of hard substances  against them in  mastication is not pro-
 ductive of any injury.   When, however, they become inflamed, in
 consequence  of decayed teeth, a cold,  or  any other  cause,  they
 cannot be touched or pressed upon, in the slightest degree,  without
 the patient being  put to a great deal  of  suffering.   Some diseases
 of the gums originate from those of the teeth;  while others  have no
 connection with this cause.

                  THE  GUM-BOIL,  OR PARULIS,

 Is merely an abscess of the gums, generally arising from the irrita-
 tion of a diseased tooth, though  sometimes from disease of  the al-
 veolary process, or from splinters of this part left  after the extrac-
 tion of a decayed  tooth.  These abscesses  are  to be treated on
 common principles, and opened  with a lancet as soon as matter is
 formed: afterwards, when the part  has become quiet, the decayed
 tooth, if there be one,  should be taken out.
   If the gum-boil become fistulous,  it  must be freely laid open,
 and a solution of lunar caustic applied.

         EPULIS, OR  EXCRESCENCE FROM THE  GUMS.

   The fibro-vascular texture of the gums is much disposed  to pro-
 duce fungous and  other excrescences.   Any kind  of  irritation, as
 that of bad teeth,  or a  severe blow,  will sometimes  lead  to the
 growth of considerable tumors from the gums; and  occasionally
 they arise without any manifest exciting cause.
   The texture of an epulis is  generally soft, spongy, and  vascular;
but sometimes hard, fibrous,  incompressible; and not  endued with
 much vascularity.
   A  soft vascular epulis mostly  originates from  the  gum itself;
 while that which has a fibrous or  fibro-cartilaginous structure  fre-
 quently grows from the  alveolary process.  When the excrescence
 first makes its  appearance between sound teeth, which it afterwards
 loosens and forces out,  it may be concluded, that the disease origi-
 nates from the periosteum and interior of the socket.
   As tumors of the epulis kind have no disposition  to recede, and,
 when they originate from the periosteum  or  bone, are  disposed to
 assume a malignant character, I cannot too strongly insist upon the
 necessity of an early operation for their complete  removal.   The
knife is the best  means for the purpose.  Any  teeth  in the way
 should be first extracted; the whole  substance  of the  swelling re-
moved; the bone and periosteum scraped; and even  a portion of the
jaw  (if diseased)  removed  with  Hey's  saw, or a  pair of cutting
forceps.  After the  removal of a  cancerous  epulis, many foreign
surgeons apply the cautery.
   The  manner of  removing' the diseased  portion of alveolary pro- 
WOUNDS OF  THE THROAT.
123
 cess is, to make a perpendicular cut through the bone on each side
 of the tumor with a fine saw, after which its separation may be com-
 pleted with a strong pair of forceps.   The bleeding is profuse, but
 may be stopped by pressing into the wound  a  dossil of  lint dipped
 in the tincture of sesquichloride of iron; the application of which,
 or of a solution of lunar caustic, may be repeated, if necessary,  at
 each succeeding dressing.





              WOUNDS OF THE THROAT

 Are cases of frequent occurrence in persons who attempt to commit
 suicide.   Some  merely penetrate the integuments, and  are  not  of
 any particular importance.    Others extend more deeply, and divide
 some of the primary branches of  the external carotid, especially
 the lingual, and superior thyroid arteries.   Others  make an  open-
 ing into the  mouth  by  separating  the os hyoides and tongue from
 the thyroid cartilage; while others are situated lower down, so  as
 to  penetrate the thyroid cartilage,  or betwixt that cartilage and
 the  cricoid, and sometimes through these  into  the oesophagus.
 Surgeons meet with more wounds of these parts, than of the trachea
 itself; for persons,  who aim at suicide, generally make the  wound
 high up in the neck, and, unless they  cut  with great determination
 and violence, they do not reach the carotid, or internal jugular vein,
 because  they hold  their heads back at the time, and thus  render
 the larynx  and  trachea prominent.    Some individuals, however,
 in a desperate state, reach  these vessels, even high up in the neck,
 dividing nearly every thing  down to the vertebrae.   Under these cir-
 cumstances, they are, of course, immediately destroyed by hemor-
 rhage.
   A simple incised wound  of the trachea, unaccompanied by injury
 of other important parts, provided all hemorrhage has  ceased, or
 can be controlled, is generally much less dangerous than a wound
 of the larynx—especially  one that penetrates the thyroid cartilage,
 so as to approach  to vocal cords and edges, of the glottis,  which
 may be involved to such a   degree  in the subsequent inflammation,
 as to  put a stop to respiration.
   Mr. Ryland, whose work contains the best observations on the pre-
 sent subject with which  I  am acquainted,  divides wounds of the
 larynx and trachea, 1st, into those which interest that part of the la-
rynx which  is situated above the attachment of the  vocal cords to
the thyroid cartilage ; and  2d,  into others, which penetrate the
cavity of the larynx  or trachea.  Wounds  in the former situation
are  comparatively free from danger,  because, unless very  deep, 
124
WOUNDS OF THE THROAT.
they do not reach the track through which the air passes in respira-
tion, and therefore the risk of hemorrhage into the trachea is absent.
The effusion of blood  into the air-tubes  is generally the immediate
source of danger  in wounds of the larynx,   or  trachea, and  hie is
more frequently lost by this occurrence than by  external bleeding.
   In ordinary cases,  when there is much bleeding, it is  from the
lingual, or superior thyroid artery.   Then   also the patient, if not
promptly assisted, may die from loss of blood, but more frequently
he faints, and this is followed  by a temporary stoppage  of the  he-
morrhage;  and time is  thus afforded for a surgeon to be sent for.
   I have known a patient die in  about twenty minutes after cutting
his throat, though no artery of any size was  wounded, and the he-
morrhage on the whole  was very trifling.   Thus,  a prisoner in the
Queen's Bench cut his throat, dividing the  trachea and the exter-
nal jugular  vein.   As he did this when he was alone in his room,
the occurrence was not known to any  other person for nearly  twen-
ty minutes after it had taken place, and when the  gentleman who
assists  me  in  the duty arrived,  the patient  was at his last  gasp:
On examination after  death, it was found that no large artery had
been cut, but the stream of blood from the external jugular vein had
passed  into the  trachea, and caused suffocation.   Bleeding even
from some  of  the numerous veins in front of the trachea, below the
thyroid gland, might have the same fatal consequence.
  I had another patient in the same place, who, after the nurse had
retired to rest, took out his razor and cut his throat.  A  girl acci-
dentally entered the infirmary directly afterwards,  and seeing the
stream of blood which went  as far as  the middle of the room, she
gave the alarm, and a  surgeon in  the  prison immediately  secured
the superior thyroid  artery that  had  been divided.  In  all cases of
this kind, the bleeding vessels are to  be secured by ligatures;  and
the edges  of the wound are not to be immediately brought together,
because, as Mr. Ryland justly remarks,  "when the immediate dan-
ger from bleeding into  the windpipe has  past away, secondary he-
morrhage may occur,  either on the establishment of reactior, cr from
the effects of ulceration; and this is more likely to be attended with
fatal results, when the edges of the wound have been  brought toge-
ther, and no outlet is  left  for the escape of the blood."
   Wounds  between the hyoid bone and the thyroid cartilage may
injure the epiglottis, the anterior wall of the  pharynx, or the lips of
the glottis,  and th§ arytenoid cartilages.  The epiglottis may be
severed from the  tongue and  hyoid bone by a  division  of the hyo-
thyroid membrane, and by then falling  over the  rima glottidis cause 4
danger of immediate suffocation.   Such a case  is recorded by Dr.
Houston, who  extricated the patient from this first danger  by rais-
  * Frederick Ryland, on Diseases and Injuries of the  Larynx aud  Trachea. 8yo.
Lond. 1837. p  234.  A work of great merit. 
WOUNDS OF THE THROAT.
125
 ing up the epiglottis, bringing it over the edge of the thyroid carti-
 lage, and fixing it there with a single stich*.   Loose portions of the
 mucus membrane, I have known cause similar distress.
   Certain cases recorded  by Larrey  prove, that the destruction of
 the epiglottis  seriously injures the voice;  that immediately after its
 occurrence, the power of  swallowing  is lost;  but that, in time, the
 lips  of the glottis are able  to  prevent  solid  food from  penetrating
 into the  larynx,  though liquids will still produce nuich  inconveni-
 ence.
   Wounds  between the  hyoid bone and thyroid cartilage may prove
 fatal by exciting  inflammation of the  glottis, and consequently se-
 rous infiltration of the submucous cellular tissue of the epiglottis and
 superior aperture of the  larynx.
   When the  knife or razor penetrates deeply into the hyo-thyroid
 space, the anterior wall  of the pharynx will  be opened;  an occur-
 rence soon manifested by the passage of liquids, taken by the mouth,
 through  the  external wound.   If  the  opening in the pharynx be
 large, so  as to be followed by a frequent escape  of the alimentary
 matters through the wound;  or if deglutition be attended with diffi-
 culty, an elastic  gum tube should be introduced into the oesophagus
 from the  nostril,  or  mouth, and food  injected through  it into the
 stomach.
   I have seen cases, in  which the  epiglottis, and also the arytenoid
 cartilages and vocal chords, were  injured.   In  one example, re-
 corded  by  Sir Charles  Bell, the divided aritenoid  cartilage, sus-
 pended merely by a membranous connection, slipped into the rima
 glottidis,  and  caused suffocation.f   A man who committed suicide,
 and  died  in  University College  Hospital,  made an oblique incision
 in the thyroid cartilage, extending upwards with such force, that the
 os hioides was cut in half.
   Wounds  penetrating  the air-tube cannot  be attended with  ob-
 structed respiration  so  long as the  external  wound  remains open;
 but in others only interesting  parts above the rima glottidis,  death
 may be occasioned  by this circumstance in  a few hours.  At the
 same time, as Mr. Ryland explains, there can  be no  doubt, that
 wounds which penetrate  either the larynx or  the trachea are attend-
 ed with much greater risk  to  life, than those which merely injure
 the epiglottis, the anterior wall of the pharynx, or the hyo-thyroid
 membrane.   In the  former cases,  death  may  ensue from hemor-
 rhage into the trachea; from suffocation,  caused by  excessive gra-
 nulations; or from a chronic  thickening of the mucous membrane,
as happened some weeks after  the accident  in one of my patients
in University College Hospital, when the outer wound and that in
* Dublin Hospital Reports, vol. v. p. 315.
t Surgical Obs. vol. i. p. 44.
               11* 
126
WOUNDS OF  THE THROAT.
the air,tube had been perfectly healed; or from extension of the in-
flammation around the wound to the lungs and plura.
   With respect to wounds of the trachea or  larynx,  complicated
with a wound of the pharynx  or oesophagus, it  is  remarked, that,
upon the  whole, the pharynx is less frequently wounded than the
oesophagus, because  it is so protected by the larynx, that it cannot
be reached unless  the thyroid or  cricoid cartilage be cut through.
When the trachea is completely cut across,  the oesophagus is gene-
rally injured.
   Certain cases, quoted by Mr. Ryland, show that the escape of
fluids taken by the mouth, through a wound in the trachea or larynx,
is not an absolute proof that  the pharynx or oesophagus is injured.
He conceives that the circumstance is  to be ascribed to some de-
fective action in the  epiglottis from the injury.
   In the  treatment,  the first  indication  is to stop the bleeding by
tying the divided vessels, if large enough to require it, whether ar-
teries or veins.
   Until  this has  been done, no  wound communicating with the
trachea or larynx is to be closed; because, if  the hemorrhage con-
tinue, the blood, not  being nble  to  pass  outwards, will flow into
those tubes, and death be likely to be produced by suffocation.
   As soon, however, as all risk from bleeding  is over,  the wound
may be closed by  position,  sutures,  plaster,  or bandage.   The
edges of wounds in the hyo-thyroid space may generally be brought
together by means of position alone.   The patient is to lie on his
back, and  the  chin  is to be  approximated to the sternum with a
bandage, the upper ends of which are to be fastened to each side
of the back part of a night-cap,  while the lower are attached  to a
band placed round the chest.   High  pillows are also to be placed
under  the head.   Adhesive plaster, or water dressing, may be ap-
plied to the external  wound.
   In Wounds of the  hyo-thyroid space,  penetrating the pharynx,
the patient is to lie upon his back, in order to lessen the  flow of sa-
liva and mucus towards the wound, and an elastic  gum tube should
be passed from the mouth or nostril, for the injection  of nourish-
ment and medicines  into the stomach.
   If urgent difficulty  of respiration should come on within a few
days after the infliction of a wound in the hyo-thyroid  space, and
this apparently from extension  of the  inflammation  of the  injured
parts to the lips of the  glottis, bleeding and calomel should be im-
mediately  resorted to, and if  not promptly  effectual, bronchotomy
should be practised.
   Wounds of the larynx require very similar  treatment  to that re-
commended for those of the hyo-thyroid space.  I  have rarely em-
ployed sutures, though Mr. Ryland considers them necessary, if the
thyroid cartilage be cut in more  places than one, and the pieces sep-
arated. 
WOUNDS OF  THE THROAT.                127
  When the wound is made in the space between the thyroid and
cricoid  cartilages, the  pharynx  is more  likely  to  be reached, than
when the knife first meets with the thyroid cartilage.   Here the use
of an oesophageal tube is required.   With respect to sutures, if,  in
this case, the gaping of the wound in the larynx  be considerable,
one or two stitches will be advantageous, on condition that they be
taken out  immediately  any obstruction  of respiration occurs.  In
wounds of  the trachea, if the whole of its circumference be not di-
vided, no sutures are necessary;  the  head is to be kept  forwards;
and adhesive plaster, or the water dressing, applied.   When the di-
vision  of the trachea is complete, position may not suffice to bring
the separated parts together, and then one or two  sutures will be in-
dispensable.
   If the oesophagus be wrounded, the oesophageal tube should be
introduced.
   The danger of closing the external wound  before the oozing  of
blood  has entirely ceased, and the risk  of its  passing  into the tra-
chea is over, has been already insisted upon.   So has the necessity
of having quick recourse to  bleeding, and calomel,  when  difficulty
of  breathing follows a wound of the air-tube, and depends upon ob-
struction of the rima glottidis from inflammation and  thickening,  or
oedema, of the lining of the  larynx,  quickly followed up, if relief
 be not speedily obtained, by  the performance of tracheotomy.
   All  patients with wounds  of the throat, inflicted for the purpose
of suicide, should be closely watched, lest they repeat  the attempt.
They  should be kept  perfectly quiet, and their minds  soothed by
good advice.   In many instances, we find great  depression of the
system, especially where the loss of blood  has been considerable,
or the individual is under the influence of some deplorable domestic
calamity.    On this account,  and  also that air of too  low a tempera-
ture may not pass direct  into the trachea through the  wound, the
chamber should be kept at a moderate  temperature.   In other in-
stances, where much reaction supervenes, bleeding  and other anti-
phlogistic means may  be called for.
   During my service  in  the army, I had  opportunities  of seeing
many  extraordinary  wounds  of the  throat and  neck.  Thus, after
the battle of Waterloo, one  man was brought  into the military hos-
 pital,  who had received the  thrust of a lance in the throat, by which
the mouth  was laid open, the tongue dreadfully lacerated, and sev-
eral of the  primary branches of the external carotid  were wounded;
consequently it became necessary to tie  the common  carotid artery.
This operation, performed by Mr. Collier, suppressed the bleeding,
and the patient recovered.   After the attack on Bergen-op-Zoom,
1 saw  a soldier, the whole of whose lower jaw, with  the soft  parts
attached to it, had been carried away by a grape-shot.   This poor
fellow recovered, and was much indebted for  this favorable result
to the  aid derived from elastic gum catheters.   In another example, 
128
WOUNDS OF  THE  THROAT.
 a musket ball had injured the carotid, in the lower part of the neck,
 which gave way about ten minutes after the soldier had been placed
 in the hospital.   No blood escaped outwardly, but  the man died of
 the pressure of the effused  blood on  the trachea, so suddenly, that
 there was no time to make any attempt to save him.

             FOREIGN BODIES IN THE OESOPHAGUS,

 Requiring extraction, are such  as might create bad  symptoms, if
 pushed down into the stomach, in consequence of their  hardness,
 indissolubility, pointed  shape, or other  hurtful qualities.  On  the
 other hand,  those which are not likely to produce harm, and are ca-
 pable of being digested, may be at once pushed down into the stom-
 ach.   They most frequently lodge about the  upper or lower  orifice
 of the oesophagus; seldom in its middle portion.  When  low down,
 the surgeon  is often compelled  to  force them into  the stomach,
 though their quality is  such as would render their extraction desira-
 ble.   In many instances, they are situated in the pharynx.  Hence,
 it is an important rule,  always to press down the tongue,  and  exam-
 ine the back of the throat, before any thing else is attempted.   Thus,
 they may frequently be discovered,  and extracted with  the fingers
 or forceps, when, from the patient's account,  one would  conjecture
 that they had descended much further.
   When a foreign body  is situated about  the  upper orifice  of the
 oesophagus, it may often^ be felt with the surgeon's finger, and if in-
 capable of being removed with it, it  may sometimes be easily ex-
 tracted with a pair of forceps,  provided the patient extend his head
 as far back as possible, so as to bring the mouth and pharynx nearly
 into the same line.  In this position,  with a pair of long-bladed  for-
 ceps, like those invented by Dr. Bond  of the  United States,  for-
 eign  bodies, nearly down to the cardiac  orifice of the stomach, may
 be taken hold of, and extracted.   A common instrument  for ihe re-
 moval of foreign bodies from the oesophagus is a kind of hook, con-
structed  of flexible wire, doubled and twisted together, and  the
 bent end forming  a noose.   In general, small  bodies, like needles,
fish-bones, &c, are more easily extracted with a piece of sponge,
introduced beyond them.   The art of employing compressed sponge
in  the most  advantageous  manner, consists in taking a piece about
the size of a chestnut, and introducing a strong ligature through it.
 The ends of the ligature  are then to  be passed through  a  flexible
catheter, and fastened to that end of it which  the  surgeon   holds.
 The sponge is then to  be introduced down the oesophagus beyond
the foreign body, and water is to be injected down the tube, in order
to wet the sponge and make it expand.   The ligature is then to  be
 firmly drawn, for the purpose of pressing the sponge against the ex-
tremity of the tube, and making it spread itself  out in  a still greater
 degree.  The tube is now to be withdrawn, together with the sponge, 
FOREIGN  BODIES  IN THE CESOPHACUS.         129
 the instrument being twisted to the right and left in this part of the
 operation.
    When the foreign substance cannot be extracted with this  instru-
 ment, a probang may be  tried, to the end  of which a  bunch of
 thread is  fastened, doubled so as to  make an immense  number of
 nooses.  In this way,  fishbones, and other substances,  frequently
 admit of being entangled, and extracted,  after other modes have
 failed.
    Some practitioners are in the habit of  giving emetics; but this
 method must be improper when the foreign body is pointed,  and is
 seldom of much use in any case,  as patients usually make  efforts
 to vomit of their own accord.
    When foreign bodies produce urgent symptoms, and  cannot  be
 extracted, it becomes  necessary to push  them into  the stomach,
 whatever may be their nature or quality; and here  it should be men-
 tioned, that substances  which one would imagine likely to  produce
 alarming symptoms by  being put into  the stomach, frequently occa-
 sion,  after they are in that organ, no dangerous symptoms, and
 even not the smallest inconvenience.   A whalebone probang is the
 instrument for this  purpose.
    When foreign bodies can neither be extracted, nor pushed  down,
 the consequences are not invaribly dangerous-   When the extrane-
 ous substance is  small  and pointed,  it frequently excites suppura-
 tion,  becomes loose, and is either carried  into  the  stomach,  or
 ejected from  the mouth.   Sometimes it makes  its way to  the sur-
 face of the neck, occasioning there an abscess, out of which it is
 extracted.
   In  some instances, foreign bodies,  especially needles  and  pins,
 after making their way through the oesophagus, travel  a great way
 about the body, and, at  length, arrive under the skin of remote
 parts, behind  the ears, at the shoulders, feet, &c, where they pro-
 duce an abscess, that leads to their discovery and extraction.   Sur-
 gical authors  mention a  variety of examples, in  which  pins and
 needles, after being swallowed, continued in  the body many years.
 In one instance, recorded by  M. Hevin,  in the  Memoirs of the
 French Academy of Surgery, a needle that  had been swallowed,
 remained in the body eighteen  years before it made its appearance
 under the skin, during all  which time not the slightest inconvenience
 was experienced.
   When the foreign body is  large, impedes deglutition, dangerously
 obstructs respiration, and  can  neither be pushed down into the
 stomach nor extracted by the mouth, the only means  of saving the
 patient's life is oesophagotomy, which  is directed by Lisfranc to be
 done as follows: the patient's head having been inclined backwards,
 an incision is to be  commenced at the inner edge of the left sterno-
 mastoid muscle, opposite the superior edge of the thyroid cartilage,
and continued down to the lower edge of the cricoid.  An assist- 
130
WOUNDS OF THE THROAT.
 ant is now to draw the carotid sheath towards the outer side of the
 wound, while  the operator cautiously  dissects  through the cellular
 tissue close to the trachea, until  the oesophagus is exposed, where
 it inclines to the left side of the windpipe.   A long, slightly-curved
 cannula, with a grooved  stilet, is  now to  be introduced  from the
 mouth down the oesophagus, and its point, being inclined to the left,
 may readily be felt in the wound.   The stilet is then to be pushed
 forwards through the oesophagus; the operator ascertains,  by  pass-
 ing his finger along the concave end of the instrument, that no  arte-
 rial branch lies over it, and then  puts a bistoury  into the  groove,
 under the guidance of which the oesophagus  is opened.   The foreign
 body, lodged in this  canal, is  now to  be extracted with a pair  of
 forceps.   The only example of  oesophagotomy  in  this  country,
 within my recollection, was performed by Mr.  Arnott.   The op-
 eration was perfectly well executed, but did not ultimately save the
 patient, who was a child of tender age.
   [Stricture  of the Oesophagus, is another disease of which  Mr.
 Cooper  makes no mention.  This is  a disease  of the passage, by
 which its calibre  is contracted,  and often to such an extent as to cause
 starvation.  It is found at various  points in the canal,  but  most fre-
 quently behind the cricoid cartilage,  at the junction of the neck  with
 the  thorax, and where the oesophagus passes  through the diaphragm.
 It is rarely met  with until after middle life, and  then is generally
 cancreous in  its character.  At times, however,  some  mechanical
 cause is concerned in its production, as in the following case.
   A. B  aged eight, some two  years previous to  coming under my
 care, had swallowed a cent; it  seemed  not to pass  into the stomach
 at once, and  she was  never conscious  of its passing from her.  Al-
 most immediately she  began to experience some difficulty in swallow-
 ing solid substances, and at length, she could get down but the small-
 est  quantity of liquids.   She  became very much  emaciated,  had
 cough, and death seemed near at hand.   I made an  attempt  to pass a
 probang, and failed with the smallest.  I however succeeded  in  pass-
 ing  a small  bougie,  and  afterwards  the smallest  sized  probang,
 through the stricture,  and continued to  dilate the contraction till  at
 the end of three  months, she was able  to swallow  nearly as well as
 ever, fattened up, and seemed well..  In  this  case, the stricture  must
 have been produced by inflammation, followed by thickening and  con-
traction of the walls of the oesophagus, caused by the cent.
  The symptoms  of this disease, are  generally well  marked, and  the
case can  always be made out, by the aid  of the prohangs.
  The prognosis, in most cases, is unfavorable ; as the stricture  gen-
 erally depends upon a scrofulous or cancerous diathesis.
  There are three modes of treatment which are resorted to, when
 any thing is attempted to be done.
  First.  Dilatation, as in the case  given above ;  and this  avails  no-
thing when the disease is malignant; but when the  narrowing of the
 passage is caused hy common inflammation, then it succeeds.
  Second. Caustic is  employed  by some surgeons ;  but 1  have  very 
WRY-NECK.
131
little confidence in its use,  in  the management of strictures in any
part of the body.
  Third, we have CEsophagotomy, as performed by Dr. John Watson,
one of the Surgeons of the  N. Y. Hospital, in  May, 1844, and this  I
believe to he the only case on record, in which this operation has been
performed for the cure of this disease.—Ed.]

                WRY-NECK.   CAPUT 0BSTIPUM.

  In this complaint, the head is drawn towards  one  of the  shoul-
ders.   In general, the face is turned towards the opposite side; but,
occasionally, towards that  to which the head  inclines.  The affec-
tion, when in a high degree, renders the head quite immoveable, so
that neither the  patient, nor any other  person, can  place it  in its
proper position.   Hence,  when the patient wishes to  look  in any
direction, except immediately before him, he  is necessitated to turn
his whole body.   Sometimes  the head can be moved, but  not
brought  into a straight  posture.   In other instances,  the patient,
with exertion, can manage to keep his head  stra;ght  for  a short
time;  but  it soon becomes  inclined again  towards the shoulder.
The disorder mostly arises from irregular action  in the muscles of
the neck, especially the sterno-cleido-mastoideus, or else from  the
contraction of a cicatrix, or  from  deformity of the cervical verte-
bra?.
   When the cause is irregular  action  of the  sterno-cleido-mastoi-
deus, this muscle, on the side to which  the head  is drawn,  has a
hard, tense, unyielding feel;  every  attempt to bring the head  into its
right position exciting  the  muscle to make greater resistance,  and
to assume a more  stretched  appearance.  Frequently the sterno-
cleido-mastoid  muscle of one side  is paralytic, and the wry-neck  is
then occasioned by the healthy ordinary action  of  its antagonist.
It may be inferred, that the cause of the deformity lies in an altera-
tion of the vertebras, when  the  muscles are free from the  above-
mentioned appearances, the  patient is  scrofulous and rickelly,  and
the head more  moveable than in the preceding case.
   The prognosis depends  on the cause and duration of the deformi-
ty.  In young  subjects, if the cause lie in the muscles, the progno-
sis  is favorable.  When, however, the case has existed a long w hile,
and particularly when  it began  in early childhood,  and  continued
during growth, the cervical vertebrae are sometimes distorted, alter-
ed  in shape, and even anchylosed: in which circumstances, the  dis-
ease is incurable.   This participation of the vertebra? in the disorder
does not  constantly  exist, at all events in an irremediable degree,
even though the disorder may have begun at  an early period of life,
and prevailed a considerable time.  Richter and Chelius  refer  to
several instances in which wry-necks of the most unpromising de-
scription were cured; cases, in which the head had  been quite im- 
132
WOUNDS OF THE THROAT.
moveable, the disease of twelve and sixteen year's duration, and its
origin had taken place in infancy.*
   When the deformity follows the contraction of a cicatrix, the cure
is  by no means easy.  A  transverse incision is made  through the
integuments  and  the head is afterwards kept in a straight posture
by some  mechanical contrivance,  until a  certain period  after the
wound is perfectly healed.   The apparatus being left off, the distort-
ed position of the head is  generally disposed to return.  It was on
this account, that Mr. Earle proposed the removal of  the whole of
the cicatrix, and having recourse to treatment already noticed in the
observations on burns.   In some instances, however, where the chin
was nearly in  contact with the  breast, in consequence  of the effect
of severe burns, I have known  considerable amendment follow the
division of the longitudinal folds in the cicatrized parts,  and the long
continued use  of mechanical means  for preserving the head in  an
even position.
   In common  examples, depending chiefly  upon a loss of equilib-
rium between the muscles of the opposite sides  of the neck, and es-
pecially upon a rigid contraction of one of  the  sterno-cleido-masto-
idei, the means  of  relief, usually tried, are camphorated mercurial
frictions over the rigid muscle, even till salivation occurs; the appli-
cation  of the  nitrate of silver to the skin; the internal  exhibition of
opium, together with mercurial frictions; electricity; stimulating em-
brocations;  the shower-bath; blisters;  issues, &c.   These remedies
should be assisted with mechanical contrivances, for gradually bring-
ing the head into a  straight position.   The best appartus  which I
know of for  this purpose, is that invented by Professor Jorg.f  It
consists of a pair  of leather stays, and of  a band or  fillet,  which
goes round the head.  On the centre of  the  forepart  of the  stays
is a kind of pulley, or groved wheel, which can be  turned round
with a key in one direction, but not in the other, as it becomes fixed
by means of a spring.   From this pulley, or wheel, a band  proceeds
up the neck to the fillet on the patient's head, to which  it is fastened
directly behind the  ear,  close  to the mastoid process.  The band
lies in  the same direction as the lengthened sterno-cleido-mastoideus
muscle, and, when  drawn towards the breast by means  of the  wheel,
it produces  the same effect as  would arise from an increase  in the
action of that muscle.   In short, it pulls the mastoid process down-
wards  and forwards towards the sternum, counteracts the  opposite
muscle of the same name, and rectifies  the position  of the  head.
The apparatus is to be constantly worn.
   When,  by perseverance in the use  of this simple invention, and
other means, the position of the neck has been improved, the head
  * Ansfangr de Wundarzn. b. iv. p. 276.  M. J. Chelius, Handbuch der Chirurgi<
b. i. p. 796,8 vo.  Leipzig. 1826.
  t Ueber die Verkrummnngcn des Menschlichen. Korpers.  4to. Leipzig, 1816. 
BRONCHOCELE.
133
is generally found to have a disposition to incline too much forwards;
an effect which the contracted sterno-cleido-mastoideus, and its an-
tagonist, the band,  both tend  to promote.  In order to hinder this,
Professor Jdrg removes the end  of the band from the breast, carries
it under the arm, and through a  ring at the side of the corsets, or
stays, and thence to the fillet on the head, where it is fastened close
to the mastoid process.   The ring hinders the band from chafing the
axilla, and following the motions of the shoulder.
   If, when the disease originates from irregular action of one of the
sterno-cleido-mastoidei, Sharp's operation of dividing the muscle be
determined upon, it  will generally  be prudent  at first only to  cut
through the clavicular portion of it.  A transverse incision having
been made over this part of the muscle, the operation is completed
by passing a director, and blunt-pointed  curved bistoury, under the
place where the division is intended to be made.   In one example,
Dupuytren passed  a  bistoury  behind the muscle,  and divided it  by
cutting forwards, leaving the  skin uncut,  in order  that the patient,
who was a female,  might not have the disfigurement of a scar in the
neck.   The position of the head was then regulated by a bandage;
and  the result was  successful.
   When a wry-neck  depends upon paralysis, or weakness of one
sterno-cleido-mastoideus,  while the other retains its natural power,
electricity, the application of  a grain or two of strychnia to the skin
which has been  blistered, setons, blisters, liniments, the  cold bath,
and  tonics,  are indicated.  The state of the bowels  and digestive
organs should also  be carefully regulated.  During  the trial of these
remedies, the head should be  kept in a straight position,  as paraly-
tic muscles are more likely to recover their tone in a tense, than a
relaxed state.   When such treatment fails, a partial division of the
healthy sterno-cleido-mastoideus has been suggested, as a means of
restoring the  equilibrium  of the  head.   At  the present  day,  we
rarely hear of operations of this kind.

                          BRONCHOCELE,

Signifies an indolent enlargement of the  thyroid gland; the tumorr
when not accidentally inflamed,  is free from pain;  and in its incipi-
ent  state, has  a soft, elastic consistence.   When it has existed some-
time, the gland loses  its  natural figure,  assumes  a firm fleshy feel,
being firmer, however, in some places, than in others, spreading to-
wards the sides of the neck,  and sometimes attaining a prodigious
magnitude.  When the adjacent cellular tissue, and lymphatic glands,
participate in  the disease, the base of the swelling may extend from
one  side of the neck to the other.   In a few instances, only one
lobe is affected.
   Bronchocele is endemic in  several mountainous countries; as, fo$-
   VOL. n.                  12 
134
BRONCHOCELE.
 instance, Switzerland, Savoy, the Tyrol, Derbyshire, &c;  and is
 most frequent in young females.   The disease is sometimes a mere
 hypertrophy of the thyroid gland; sometimes an  excessively indur-
 ated, or even  a partly ossified condition of it; and, in other instan-
 ces,  the swelling  consists of many cysts of different sizes,  filled
 with transparent viscid fluid,  or matter of various kinds.   The tu-
 mor sometimes creates no particular inconvenience, and is merely a
 deformity.   When large,  however, it is  frequently attended with
 considerable obstruction of the speech, respiration, and deglutition.
 It has little  tendency to  become malignant, that is to say, cancer-
 ous,  and is  not  very liable  to inflammation and its  consequences,
 though these changes sometimes happen.   In Mr. Langstaff's mu-
 seum is a fine  specimen of fungus haematodes of the thyroid gland,
 which had been mistaken for bronchocele.
   The causes of bronchocele are involved in great obscurity.   At
 one time, it was conjectured, that drinking water,  obtained from melt-
 ed ice or snow, frequently gave rise to the disorder.   The disease,
 however,  is frequent in Sumatra, where  ice and snow are never
 seen; while it is entirely unknown in Thibet, where the rivers are ex-
 clusively supplied by the melting of the mountain's snow.  Broncho-
 cele has been  regarded as a scrofulous complaint; but this doctrine
 is denied by Prosser*, who argues, that the disease is often seen in
 persons entirely  free  from every  mark of scrofula; and that,  while
 boys are as  subject to scrofulous  diseases  as girls, bronchocele sel-
 dom occurs, except in young females.
  Formerly, the medicine commonly given for the cure of broncho-
 cele, was burnt sponge, in the dose of a scruple, two or three  times a
 day, either made into an electuary with syrup, or prescribed in the
 form of a lozenge, the efficacy of which was  thought to be greatest
 when it was placed under the tongue, and allowed gradually to dis-
 solve there.    A mercurial purgative was usually  given about once a
fortnight.   The good effects of burnt sponge are  now well known to
 depend  upon the iodine which it contains, and, consequently, at the
 present day, iodine itself is commonly  prescribed.  Its  efficacy is
promoted by the previous application of leeches to the  swelling, and
 a low regimen.
  With such treatment, external means are to be combined; as re-
peated frictions of the swelling with strong camphorated or ammo-
nia liniment, or, what is still  better, the ointment of the  iodide of
 potassium,  with or without  a  proportion of mercurial  ointment
 blended with it.
  From the foregoing description of the very different conditions of
Method of Cure of the Bronchocele, or Derby-neck, 3 edit. p. 
ERONCHOCELE.
135
♦he thyroid gland in different instances,..it is manifest, however, that
iodine will not cure every form of it.
   Accident has sometimes  furnished useful suggestions in the prac-
tice of surgery: bronchoceles have occasionally festered, or ulcerat-
ed, and the result  sometimes been the dispersion of most of the
swelling.   Hence, the plans of forming issues and setons, as a mode
of cure.  Valuable  information, respecting the  effects of setons,
may be collected from a paper  by Dr.  Somerville, describing the
practice of Quadri  at Naples, and inserted in the Med. Chir. Trans.
vol.  10.; and  from another paper in the eleventh volume, drawn up
by Mr.  Copland Hutchinson.  The seton was often'employed by Du-
puytren.   It should never be made, except when iodine has decid-
edly failed, and  the complaint is beginning to be very  oppressive.
If a seton  be  passed through the thyroid gland, the  hemorrhage is
always profuse, and might prove dangerous, were it not checked by
cold applications, and pressure.  In general, the seton must be kept
in several  months,  before the swelling is completely reduced.  It
will not cure the hardest forms of bronchocele; but it will cure hy-
pertrophy, cysts, and hydatid formations,  which iodine and other
specifics frequently fail to disperse.
   If this latter measure, or the formation of an issue, should not be
deemed advisable, and  the patient's life be rendered  miserable, or
seriously endangered by the pressure of the swelling on the trachea,
oesophagus, and veins returning the blood from the head, it will be for
the  practitioner to  consider,  whether he will imitate Blizard, Wal-
ther, Wedemyer,  Graefe, Coates, Brodie, &c. in tying one or both
of the superior thiroid arteries, or follow the example set by Gooch,
Desault, Theden,  Vogel, and Hedenus, who ventured to extirpate
the enlarged thyroid gland.   The latter surgeon has performed this
bold operation,  at least six times, with complete success.   The
most essential rule  in the operation would be to secure  every large
artery directly after it was cut, so that the patient might not be lost by
hemorrhage, ere the complete detachment of the swelling had been
effected.   The ligature of  the superior thyroid arteries  is generally
followed by some  diminution of  the tumor, but this amendment has
not always been permanent.   In some of the cases on record, the
patients died  either of inflammation  and its consequences, or of
secondary hemorrhage.
   In one example  that occurred in University  College Hospital,
Mr. Liston exposed a large prominent portion  of the tumor,  and
after carrying the  dissection  as far as he deemed safe,  passed a
double  ligature through its base, and thus effected its destruction. 
13G
               WOUNDS OF  THE CHEST

Are divided into superficial  and penetrating.   The former do not
materially differ from common  wounds of the skin and muscles in
other situations, and therefore do not here require particular notice.
  When we consider the important organs contained  in  the chest,
we  should hardly suppose it  possible for a bullet or a sword  to pass
across it without  inflicting a mortal wound.  Yet, recoveries from
such injuries are frequent, and  this notwithstanding they may be
complicated with a wound of the lungs.   Nay, facts are recorded,
which leave no doubt, that  even wounds of the heart  itself  are not
always fatal, balls having been found encysted in its substance, after
death from other causes, long after the receipt of the wound.
  When, in respiration, the air passes alternately into and out of a
wound in the parietes of the chest,  we know that the weapon must
have penetrated  beyond the pleura costalis.  In  the  expansion of
the thorax by the muscles of inspiration,  the air enters the wound;
in its contraction  by the muscles of  expiration, the air is  pressed
out in a more or less  forcible current.  When the communication
between the cavity of the pleura and the atmospheric air is free and
ample, the lung generally collapses, unless prevented by adhesions;
and the  knowledge of this circumstance led to the belief,  that if di-
rect openings  were made simultaneously  into both cavities of the
pleura, the patient would inevitably  die of asphyxia produced by the
collapse of both lungs.  Experience  proves,  however, that this  is
not the  fact, and that recoveries may  follow wounds penetrating the
two sides of the chest, even where  the admission of air to the  cavi-
ties of the pleura is free and direct.   Three chief sources of dan-
ger present themselves in all penetrating wounds of the chest.
   1. The risk of profuse internal hemorrhage, by which the patient
is sometimes destroyed  at once; or by which he is more slowly cut
off, generally in consequence of the extravasation in the pleura pro-
ducing too much pressure on the lungs, or becoming combined with
inflammation of those organs.
  2. Other patients fall victims to inflammation within the chest,
without any effusion of blood,  though sometimes  the  inflammation
is followed by abscess, or, as it is here called empyema.
  3. Another cause of danger, when the lungs are wounded, is em-
physema, or the inflation of the cellular tissue, sometimes of the
greater  part of it throughout the body.
   The symptoms of a icound of  the lungs are, bloody expectora-
tion immediately after the receipt of the injury, frequent  coughing,
great difficulty of breathing, a feeling of suffocation, and  a  sudden
alteration of the countenance, which exhibits paleness  and marks of
great anxiety.  Here the immediate danger is either from  the quan-
tity of blood withdrawn from the circulation by  internal  hemorrhage; 
WOUNDS OF THE CHEST.
137
or from the passage of that fluid into the bronchi and air-cells of the
lungs;  or into the cavity of the  pleura, so as  to cause suffocation.
Hence wounds of the  root or upper part  of  the lungs, where the
vessels are large, are always the most dangerous.
   With regard to the treatment, it is a general rule to close all
such wounds without delay.  We  ought, however, to extract any
splinters of a broken rib, a ball, a portion of the clothes, or any other
extraneous substances  wich lie near the  surface, and can  be easily
reached without too much irritation.  With respect to a woundedinter-
costal artery, all the best modern practitioners disapprove of the intro-
duction of various instruments and  contrivances into the wound or
chest for the suppression of the bleeding.   Dr. Hennen had heard of
examples, in  which the intercostal  artery was taken up with a te-
aculum.  But  supposing this were  not practicable,  I believe, that
less danger would arise from closing the wound and applying a com-
press over it,   than from the introduction of extraneous  substances
round  or within the rib.   I attended, with Mr. Frogley  of  Ilouns-
low and Mr.   Broxhohn of Sunbury, a young gentleman, one of
whose intercostal arteries was wounded by a small knife.   The re-
sult was a prodigious  effusion  of blood  under the  muscles of the
back,  followed by large  collections of matter,  and very urgent  dan-
ger; but, in the end, the patient recovered.  No attempt was made
to secure the  vessel.  About eight ounces  of blood flowed out of
the orifice of  the wound  directly  after  the accident; the outward
hemorrhage then ceased;  but the blood  accumulated in the cellular
tissue;  great swelling ensued, and,  in about eight days, such a quan-
tity of matter and putrid blood was suddenly discharged from the
external wound, that the patient lay in  a  kind of  pond,  extending
from his feet to his neck.   Incisions were occasionally practised to
facilitate the exit of the matter.   It was some months  before the dis-
charge ceased, and the wound  closed.  In the  early inflammatory
stage,  leeches and venesection were freely employed.
   In all penetrating wounds of the chest, and especially those extend-
ing into the lungs, the  free use of  the lancet  is the  only thing that
can be  depended  upon  in  the beginning,   it is by this  means that
internal  hemorrhage  is  to  be  checked;  and  inflammation of the
lungs  prevented  or subdued.   Here, as  in  certain injuries of the
head, moderate bleeding will not suffice. We may perhaps be requir-
ed to bleed the patient more than once a day  for six or  eight  days
in succession.   The first  bleeding  should be copious;  and, if the
patient faints,  should not give him cordials, but allow him to revive
gradually without ihem.
   When  the oppression  of breathing returns, and the  pulse rises,
accompanied by pain in  the chest,  and spitting of blood, venesec-
tion should be performed again; and thus the lancet is to  be used
as often as the  state of the circulation, the pain, and  oppression of
                            12* 
138
WOUNDS OF  THE CHEST.
breathing, or other circumstances call for  it.   If we  neglect this
rule, we are certain of losing the patient.
   VVhen the paroxysms of pain, the sense of suffocation,  and the
internal hemorrhage are lessened, but the cough is severe, we may
prescribe digitalis or hyoscyamus, with small doses of the acetate
or muriate of morphia, and saline medicines.
   When much cough and pain in the chest continue,  after  bleed-
ing has been carried as far as practicable, a blister may often  be
applied to the  chest, with great benefit; and, sometimes, leeches
or cupping may yet be ventured upon, though venesection itself  is
not any longer admissible.
   When matter forms in the cavity of the pleura, after a wound  of
the chest, constituting empyema, or  when the extravasation of blood
in the  chest causes urgent clanger by its pressure, the indication  is
to make an outlet for the discharge of  such  fluids;  but,  if the
wound  should  not be closed, we ought  to avail  ourselves  of the
opening  already existing  for (his purpose;  and, with this view, di-
rect the patient to  lie in a posture that will render the wound de-
pending.
   In former days, when blood was extravasated in the chest, surgeons
used to make themselves particularly officious about its  evacuation,
sometimes using tubes and syringes for the purpose.   But, at present,
we never hear of such schemes being put in execution.  This  part  of
surgery, however, is sometimes attended with a great deal of perplexi-
ty; for we have two dangers to contend against,—one is that of let-
ting the patient die  of suffocation from the  pressure of the blood on the
lungs and diaphragm, if  no opening be made  for its discharge; the
other  is that of seeing him fall a victim to  continued hemorrhage if
such opening be made.   I believe, however, that the experience  of
army surgeons, who are the best and most experienced judges of this
subject, will justify me in saying,  that we shall generally act with
most prudence if we do not hastily adopt schemes and contrivances
for discharging blood from the  chest, but rely upon rigorous anti-
phlogistic treatment.   The diagnosis also is rarely so  clear, with
regard to an extravasation of  blood, as to justify the performance
of an operation for its evacuation.   At all events, we should  not be
in too  great  a  hurry to make an opening in the chest;  but give na-
ture an opportunity of doing her best, under the assistance  of the
treatment which I  have advised.
   Sometimes wounds of the chest are complicated with profusion
of a portion of the lungs: one such case was brought to meat Brus-
sels after the battle of Waterloo.   The protruded  piece of lung
was of a long, narrow, tongue-like form,  and  severely  contused.
The wound had been made with a lance.   I thought at first  of cut-
ting the protrusion oft", but the bleeding made the  inclusion of it  in
a ligature necessary.   The patient,  I believe, did not ultimately
recoyer. 
EMPHYSEMA.
139
                         EMPHYSEMA,

Or the inflation of the general cellular tissue, is frequent in cases of
fractured ribs with  wounded lungs,  because the air has no outlet,
the skin being entire.  It seldom occurs  as  a complication of a
free and direct wound, but chiefly of those, whose  orifices are nar-
row,  and whose direction is oblique, as  is the case with punctured
wounds in general.  It is  not  uncommon  in  cases  of  gunshot
wounds of the chest, their  orifices being blocked up by  the swel-
ling around the wound, and  the sloughs within  it.   Emphysema is
not confined to examples of penetrating  wounds of the chest, or of
broken ribs, but may take place  in any  situation  in  the vicinity of
the organs and  apparatus of respiration.   Hence, emphysema of
the eyelids from fractures of the os ethmoides, os  unguis, or fron-
tal sinus,  or  from  a laceration of the  mucous  membrane of the
nose."
   The symptoms  of emphysema  are, great oppression of  the
breathing,  inability to lie down, or a preference to an upright or sit-
ting  posture;  a colorless,  elastic, crackling tumor, beginning near
the wound or fractured rib,  and often extending with great rapidity,
so as to cause  sometimes  an enormous distension of  the  cellular
tissue  of every part and region.   The chief cause  of danger, how-
ever, is not this diffusion of air in the subcutaneous cellular tissue,
but its insinuation into the interlobular cellular  tissue of  the lungs,
and its accumulation in the  cavity of the pleura,—two circumstan-
ces causing a perilous obstruction of the  function of respiration.
Emphysema is also frequently combined with the danger depending
upon  inflammation,  effusion  of blood, or lodgment of foreign bodies
in the  chest.
   Experience proves,  that when emphysema is restricted to a mode-
rate space, and only a few cubic inches of air are within that space, it.
is readily absorbed  again.   But circumstances are different, when it
has passed, not only into the whole of the cellular  tissue under  the
skin,  and between the  muscles,  but into that of the viscera of the
thorax, and even of the abdomen; and likewise into the great cavi-
ties lined  by serous membranes.  The  mechanism, by which  the
air is  impelled  into the cellular  tissue, is an interesting part of the
subject.   When, in consequence of previous  inflammation of the
chest,  there exist organised  adhesions between the two pleura?,  and
a continuity of tissues  is thus formed  between  the surface of the
lung and the parietes of the  chest, emphysema is very easy  of com-
prehension.  The air then passes from the interior of the  lungs  into
  * See Dupuytren, I eqons Orales, t. i. p.  123.  A footman, in the service of ihe
Duke of Sussex, w;is lately under my care in Universiiy College Hospital, with a
fracture near the inner side of the right orbit, accompanied by emphysema. 
140
EMPHYSEMA.
the interstices of the new organisation, and afterwards,  gradually
making its way through the parietes of the chest, gets into the sub-
muscular and subcutaneous cellular tissue.   Here we are supposing
the weapon, or point of a  fractured rib, to  have pierced  the lung
precisely in the seat of such adhesions.   But, when there  are  no
adhesions,  the air, which is inspired, partly escapes from the breach
in the surface  of the lung,  and passes at  first into  the  surrounding
tissues and cavity of the pleura.   Thence it is next forced  by the
influence of the  contraction of the chest in respiration.   The ex-
pansion, or act of  inspiration, draw's the air first  from the  breach in
the lung into the cavity of  the pleura, and thence it is propelled in-
to the cellular tissue adjoining the wound in the side, by the diminu-
tion in the capacity of the chest in each expiration.   In other words,
each inspiration draws it out of the rent  in  the lung into the cavity
of the pleura, and each expiration pumps  or compresses it out of
that cavity into the cellular tissue, for it cannot  return into the air-
cells, on account of their being  already full of air themselves.  Its
progress over the body is also, no doubt, facilitated by its  own elas-
ticity.   The  quantity  of it, thus  diffused,  is sometimes enormous,
filling not  only the  parietes of the thorax and abdomen,  the upper
and lower extremities, the  loose cellular texture of the scrotum, the
neck and head, but also the pleurse, the mediastina, the pericardium,
and even the  interlobular cellular tissue of  the lungs.
   The  treatment varies according to the degree of emphysema, and
the urgency  of  the symptoms  arising from it.  In-cases of only
moderate extent, attended  with broken ribs, a compress may be ap-
plied over  the swelling,  and then  a bandage round the chest, follow-
ed up by venesection and  opening medicines.  The object of the
bandage is to suspend the action  of the intercostal muscles, and to
makethe  patient breathe entirely  by  the  diaphragm, so as  to pro-
mole, on the one hand, the union of the fractured rib, and, on the
other, to resist, as  much  as possible, the  causes  of emphysema.
In  emphysema  of great extent,  as I have  explained, one principal
risk proceeds from the  accumulation  of air in  the  cavity of the
pleura,—a s.ate indicated  by a  metallic  tinkling sound, compar-
ed  to   the dropping of  shot  into a  porcelain  basin; and, there-
fore, when scarifications  do not  give  relief, and  there  is reason to
believe, that air is confined  in the chest, we should make a deeper and
freer incision over the broken  part of the rib, or enlarge the original
wound, and puncture the pleura costalis.
   Slight scarifications and  a  bandage round the chest will tend to
prevent the increase of emphysema  in  the  common cellular tissue:
and may,  indeed, be of important utility  in hindering its  extension
into this texture  so far as to reach the interlobular cellular substance
of the lungs.  Yet, in more aggravated cases, I believe with Baron
Dupuytren, that they are inefficient means, and  also that  the  pres-
sure of the bandage would  really make  the state of the   breathing 
WOUNDS OF  THE  BREAST.
141
worse.  In urgent or rapidly  increasing cases, therefore,  perhaps,
the most prudent plan is  to make an  incision, and then cautiously
puncture the pleura costalis.  However, nothing will answer,  if the
cellular  tissue of internal  organs is already much  inflated.
  The place for the incision and puncture is determined by the frac-
ture, or original  wound, where the air first escapes  from the chest;
but, when the intention is to let out blood, water, or  purulent mat-
te, we are  to  divide the integuments over the space between  the
sixth and seventh ribs, where the  indigitations of the serratus mag-
nus meet those of theobliquus externus, and, having cut through the
intercostal  muscles, cautiously puncture the pleura.
   The  incision through the intercostal muscles should  be  made
away from the lower edge of the rib, where the  chief branch  of the
intercostal  artery runs.
             DISEASES  OF  THE  BREAST.

   The classification of diseases of the breast, adopted by Sir Ast-
ley Cooper, is,
   First, into diseases, the result of common inflammation, whether
acute, or chronic.
   Secondly, into diseases accompanied by peculiar or specific action,
but which are not malignant, and do not contaminate other structures.
   Thirdly, into others, which not only consist in local, malignant,
and specific actions,  but are  connected with a peculiar and unheal-
thy state of the constitution,  and affect with  similar disease, besides
the part originally attacked,  others in the neighborhood, and  even
sometimes remote parts.
   The first class of  diseases comprehends:  1.  Acute inflammation
of the breast, and the milk abscess.   2. Chronic inflammation, ter-
minating at length in suppuration.  3.  The lacteal tumor, so called
by Sir Astley Cooper, on account of its arising from obstruction of
one of the  lactiferous tubes, as an effect of chronic inflammation.
To this arrangement I shall  confine myself, after noticing a few dis-
eases of the  nipple.

 DEFICIENCY OF THE NIPPLES, OR  THEIR NUMBER GREATER
                         THAN  USUAL.

   Sometimes there is congenital absence of  the nipple; sometimes
it is accidentally obliterated  by wounds, pressure, a burn,  venereal,
or other forms of ulceration.   Under any of these circumstances,
there  is an impediment to the excretion of the milk, which can only 
142
EXCORIATIONS.
 be determined from  the breast, as much as possible, by the action
 of purgatives.
   The nipples may exceed their  usual number; for instance,  there
 may  be two on each breast, or even as  many as five.*   The re-
 moval of the superfluous  nipples is evidently the proper measure;
 but, as there is a risk of mistaking the natural nipple itself for the
 abnormal ones, Boyer may  be  right in advising the operation to be
 deferred until after the birth of the first  child, when the true nipple
 will be ascertained.
   Sometimes the nipple is  imperforate from birth.  This condition
 may not become known until after the subject of it has been deliver-
 ed of her first child.  Such a case is generally incurable.

                        EXCORIATIONS.

   The greater number of women who suckle for the first time, ex-
 perience, more or less,  tenderness of the nipple.   But, frequently,
 in consequence of being incessantly  irritated by the child's mouth
 and the lodgment of milk upon  it, it inflames, and becomes excoriat-
 ed.
   Various plans  of relief are adopted for excoriations of the nipple.
 One consists in  letting the infant suck only at longish intervals, and
 keeping the  part  covered with  a piece  of fine soft linen.  If this
 should not answer, the nipple  may be bathed several times a day
 with the lotio plumbi acetatis, or the  linementum  calcis.   Sir Ast-
 ley Cooper prefers an application, composed of 3 j. of borax,  5 ss.
 of alcohol, and Sj.  of  water.   M.   Velpeau, if simple ointments
 fail, employs a weak solution of the nitrate of silver, or sulphate of
 zinc, or an ointment containing  white precipitate.
   But it is always to  be recollected, that the child's suction  is the
 exciting cause of the complaint, and that several of the applications
 above  specified, would be productive of inconveniences,  if allowed
 to remain on the nipple  when the infant sucks.   Hence, under such
 circumstances, an artificial nipple, made to fit  accurately, is some-
 times deemed one of the best means  of relief.   With the aid of this,
 and cleanliness, and some of the applications, enumerated, a cure is
 generally accomplished  in a few days.f   In some cases,  the child
 should take milk chiefly  from the opposite breast.

     ULCERATED FISSURES,  OR CRACKS  IN THE NIPPLE,

 Which arise  from the same causes as  excoriations, may occur on
 different points of the areola, or on  the nipple  itself.   In conse-
quence of being stretched and  irritated whenever the infant sucks,
       * Acta Havniens, vol. iii. Obs. 98.
t See Velpeau, Mai. du Sein. p. 4 8vo. Paris. 1838. 
DISEASES  OF THE  BREAST.
143
they extend  more and  more  deeply, and cause  acute suffering.
Sometimes they  become  so  large  and deep, that,  whenever dis-
turbed  by the child, they  bleed profusely;  and,  occasionally, they
penetrate the base of the nipple so far, that the latter part is in dan-
ger of  being  completely  detached.   Hence, from the severity of
the inflammation  the secretion of milk and  suckling  are sometimes
quite interfered with.*
   The treatment  should be like that of excoriations; artificial nip-
ples being here even  more necessary.   The applications in com-
mon use are the calomel  and  lime water lotion: zinc ointment;  or
the nitrate of silver; with which all the surface of the  fissures should
be carefully rubbed  at  intervals.  I concur  with  M. Velpeau  in
thinking lotions of the bichloride of  mercury improper,  as likely to
poison the infant.
   In women, who  have long ceased to suckle, the nipple is some-
times  attacked with a combination of chronic eczema and psoriasis.
In two cases, recorded by M. Velpeau, the disease  had continued
for several years,  attended  with itching, and thick  greenish,  or yel-
low scabs, but no inflammation.   He ascribes  its commencement
to the  friction of the  corsets against the breast.   One patient was
cured  by the use of an ointment, containing  white  precipitate;  the
other  submitted to the excision of the diseased nipple.

                   THE  LACTEAL  SWELLING,

 Is confined to the nipple, and consists of a large collection of milk,
partly fluid, and partly coagulated, often mixed with pus, in one of
the lactiferous tubes, the aperture of which has been  stopped up  by
chronic inflammation.  It is a disease analogous to ranula.  The swel-
ling presents a distinct  fluctuation; the cutaneous  veins are  large;
but the color of the skin is not changed.  If a slight puncture  be
made, it soon heals, and another accumulation takes  place; or, if a
small  ulcerated  opening form, a little way from  the  nipple, it con-
tinues  during the period of suckling, and  the milk,  instead of pass-
ing into the child's mouth, is  lost.
   The origin of the lacteal tumor is  referred by M. Velpeau to sud-
den exposure of the breast  to cold; too abundant  a secretion of
milk;  and too long retention of it.   Rough  suction of the nipple,
and the  free  use of cordials, will also promote its  occurrence.
   A  puncture  of moderate size will suffice, if the  child is wean-
ed; if not, a larger opening  must be made, so as to let the milk
escape while the child is sucking, until the secretion of milk ceases,
or the child is  weaned.   This is the  advice given  by Sir  Astley
Cooper.
   If a small lacteal fistula were to be left after the puncture, or to
* See Velpeau, Op. cit. p. 6. 
144
DISEASES  OF THE  BREAST.
follow an abscess communicating with one of the lactiferous ducts,
M. Velpeau is in favor of touching it at intervals with the nitrate of
silver, and  applying  astringents.   This practice he  finds almost al-
ways  successful.   If it should not be so, he recommends injecting,
twice a  day a weak solution of nitrate of silver, or alum,  or lotions
containing  tincture of iodine,  or  red wine.   Were this  plan not to
succeed, he would  dilate the  orifice in the skin, and apply the ni-
trate of silver freely to the inside  of fistula.  By one or the  other
of these methods, M. Velpeau has never met with a lacteal fistula
that was not cured.   If the patient were not obliged to suckle,  these
means would cure the fistula still more  quickly.  Compression, and
internal medicines might also  be employed.*  Dupuytren gives an
account of cysts  filled wih a milky or buttery matter, which he had
found in the breastf;  and which  contained a milky substance either
in a liquid, half-liquid, or imperfectly curdled state;  but M. Velpeau
is  not aware that  solid tumors, really formed by the milk have been
hitherto described.   Certain irritations of the texture of the breast,
he conceives, may lead to infiltration of the milk out of the lobules
or excretory ducts of the mammary  gland, so as to form abnormal
collections of it,  just as blood is extravasated from its vessels as a
consequence of blows.  M. Velpeau,  in 1838, attended a woman,
whose breast  was transformed into a spongy, highly-sensible mass;
an exploratory puncture was made in it, and a quantity of  milky flu-
id was discharged, which manifestly issued from the cellular tissue.
But  he is  of opinion  that  the  actual escape  of milk from its
proper vessels is  not essential to the  production of  true accumula*
tions  of it.  The lactiferous tubes may be dilated, and transformed
into cysts of considerable  size.
   [This enlargement arises from a closure of one of the  lactiferous
tubes, the true glandular structure,  with which the tube is connected,
being in a  normal state.  It occurs  only during  lactation, is rather
slow in  its  growth, and is unaccompanied by  pain.   Whenever the
gland secretes, the milk is thrown into the obstructed tube, which di-
lates sometimes to an enormous  size.   Sir Astley  Cooper says these
tumors  sometimes contain several  ounces.   The  following case, is
the most remarkable for size on record.   The patient was a healthy
Irishwoman about thirty years of age,  who  presented herself at my
clinique in January,  1842.  She had been nursing  her  child  about
nine months.  About  six weeks  before 1 saw her, she discovered  a
tumor in the breast,  which she could not trace to  any cause, as she
had received no injury, and had felt no pain.  The  breast was enor-
mous, and  there was evident fluctuation.  On being punctured, three
quarts by measure of apparently good milk were drawn off  She was
directed to wean  her child, and return the next week.  She came as
desired  : the wound had closed, and two quarts more of milk had ac-
cumulated  in  the breast, which  were again drawn  off.    The  milk
♦ Op. cit. p. 48.              f Poillard, Jour. Hebdom.  1829. 
THE LACTEAL
SWELLING.
145
seemed  sweet and unchanged,  and  produced on  standing, a large
amount of cream.   After tins lime 1  did not see the patient.
  These tumors are generally cured  with great ease, by puncture and
weaning the child.                                        Ed.
  Vid. N. Y. Med. Gazette for January 1842.]
  M.  Velpeau believes, that milk  effused in the breast may,  like
extravasated blood, remain a long while, and be the cause of much
pain; or, that it  may be decomposed, and lead  to the formation of
a cyst filled with  serum, if the curd is first absorbed, or filled with
semi-fluid matter, if the serum is first taken away.  In other cases,
the  effusion  of milk may cause inflammation  and milk abscess;
or,  again,  in others,  being  cnce coagulated in the  lactiferous
tubes, or  interlobular tissues, it  may  become blended with the
fibro-cellular  element,  concrete, and  harden more and  more, and
thus produce what M. Velpeau terms a buttery or caseous tumor of
the breast.   It is less necessary for us to adopt the foregoing theoreti-
cal explanation, than to remember the fact, that the breast is liable,
to tumors of this  nature, which sometimes attain a large size.   It is
curious to learn also, that, in the  case recited by M. Velpeau, tum-
ors of the same kind were developed secondarily, as medullary masses
in the axilla, and under the clavicle.   The tumor of the breast it-
self, after  being  completely  removed, was  reproduced.*  These
latter  particulars lead me to suppose that,  whatever  might  have
been the first state, or cause of the formation of this tumor,  it was
afterwards of the nature  of medulary  cancer; a  disease, which, in
some of its varieties, we know is  as liquid as cream or milk; though
in others of the encephaloid consistance or even much firmer,  as ex-
emplified  in  Abernethy's mammary  sarcoma.f   The  great  size
which the swelling of the  axillary  glands  attained,  viz., that of a
child's head,  and its Iobulated shape, tend to confirm  the view to
which 1 incline.   However,  caseous matter  is described as issuing
from ulcerated parts of the tumor;  and M. Donh£,  who, in one in-
stance, examined the substance compared to cheese, or  butter
somewhat altered, found in it numerous globules, which, in the mi-
croscope, resembled those of milk,  and, like them, were found also
to be  soluble in  ether, and  alcohol, and insoluble in ammonia.
They were likewise blended with mucous  globules, and the minute
granular bodies, characteristic of colostrum.
   In the treatment of solid milk  tumors of the  breast  in the  early
stage, and where the milk appears to be diffused in the breast by in-
filtration, M. Velpeau recommends leeches, or even  venesection,
and active purgatives, followed by liniments of camphor or ammo-
nia.  But,  if distinct  Iobulated  prominences present themselves,
quite concrete, and the diseases of  long standing, he deems the ex-
         * Velpeau, Op. cit. p. S3.
         t See Carswell'a Elementary Forms of Disease.
VOL.  II.                    13 
146
DISEASES OF  THE  BREAST.
 tirpation of the tumor the only chance of saving the patient.   1 ap-
 prehend, however, notwithstanding some particulars calculated to
 support his view, that my friendly correspondent, M. Velpeau, may
 have mistaken a variety of medullary cancer for a tumor  composed
 at first of effused, and afterwards of curded, milk.

          ACUTE  INFLAMMATION  AND  MILK ABSCESS.

   Inflammation and abscesses of the breast admit very well  of the
 division adopted by M.  Velpeau, into the subcutaneous, the deep, or
 submammary, and those  of the mammary gland itself.
   Women, during the period  of suckling,  are particularly liable to
 inflammation and suppuration of the breast:  hence, the  term milk
 abscess.   The inflammation is of the  phlegmonous kind,  exhibiting
 all its usual characters;  but, on account of the  sensitive nature of
 the  part,  and the  envelopment of it in a dense  cellular or  fascial
 covering,  not readily yielding to inflammatory swelling, the suffering
 is uncommonly severe.   A solid swelling is produced,  succeeded
 by a blush of inflammation on its  surface, and at length a  promi-
 nence and smoothness in one particular situation,  where the fluctua-
tion  of matter may be felt,
  The most  frequent cause of milk abscess is the great  determina-
 tion  of blood to the breast each time the child is  about to suck,  by
 nurses called the draught, combined with the mechanical  iritation,
 to which the  part is continually subjected.   The  origin of such  ab-
 scesses  is sometimes  promoted by the child  not being  put  to  the
 breast soon enough after  birth;  consequently the breast becomes  too
 full;  and this state, influenced  by the  stimulating  diet often pressed
 upon mothers by nurses, soon  ends in .acute inflammation.
  In the early stage, we may  sometimes bring about resolution  by
 employing cold evaporating lotions,  leeches,  and  purgative  medi-
 cines.   All action of the great pectoral muscle should be prevented
 by keeping the arm in a sling;  and the patient, when in bed,  should
 lie on the  opposite side.   If the breast  be very large, some  practi-
 tioners keep it supported with a bandage; a method, which I  do  not
 usually follow.   Amongst the  causes of this complaint, I  have men-
 tioned the mechanical irritation  and disturbance of the breast in
 suckling.  Hence,  I  always  advise the  mother not to  allow  the
 child to suck the inflamed breast; and, if it be necessary to draw
 the milk from it,  recommend  the  use of a glass tube made for  the
purpose.
  When an abscess cannot be prevented from forming,  cold  appli-
cations are to be discontinued,  and emmolient poultices and  poppy
head fomentations substituted for them.
  With respect to the  question of opening the abscess, I may ob-
 serve, that if the  collection of matter be superficial, not attended
with  extreme pain, and quick in its progress to the surface, it is not 
          ACUTE  INFLAMMATION  AND  MILK  ABSCESS.       147

of great consequence, whether the  abscess be  opened, or allowed
to burst of itself;  but when the abscess  is deep,  its progress tedi-
ous, and the  pain  severe, and  accompanied by  fever, the matter
should be let out.   But, even  with regard  to  the most superficial
abscesses, some practitioners prefer opening them at once, so  as  to
obviate all risk of  the skin becoming undermined by them.   I see
no objection to the practice, for otherwise  sinuses may form, and
the cure  be  rendered  more  difficult and  tedious.  "Abscesses  in
cellular and  fatty texture of the breast,"  says M. Velpeau, "should
be opened, and this very freely as soon as a fluctuation can be plain-
ly felt.   I will add, that making a puncture in the  centre of such
abscesses, even before they  are completely mature, appears to me to
check their  progress, and promote  their  dispersion."  The punc-
ture should be made in a depending situation, and if  the skin be ex-
tensively thinned, or sinuses exist, incisions should be made at diffe-
rent points.*
   Some cases are  exceedingly  obstinate, in consequence of several
abscesses following one another in  succession.   Here the  adminis-
tration of opium and the sulphate of quinine will be found beneficial;
and  when a  deep-seated  abscess, in consequence of not being
opened freely or  soon enough, leads to the  formation of sinuses
in various directions, which continue to discharge matter for a long
time, if they cannot be healed by pressure, we  may follow Sir Ast-
ley Cooper's  plan, which is, to inject into them a lotion of  rose
water, with  every  ounce of which two  or three  drops of concentrat-
ed sulphuric acid are blended, and apply the same lotion to the sur-
face, and sometimes  a bandage:   Mr. Hey, of Leeds, was an ad-
vocate for laying open all  sinuses  of  this kind; and  M.  Velpeau
strongly insists upon the advantages of such practice, with the con-
dition, that it be restricted to cases, where the  fistulas  have existed
several  weeks or  months,  and ordinary incisions and other means
have failed.    While M.  Velpeau  gives  his testimony in  favor  of
opening superficial, subcutaneous,  and submammary  abscesses  of
the breast early, he recommends not opening those of the mammary
gland itself,  until a fluctuation is very distinct.  In the latter cases,
also, he finds, with M. Donne,- that the  milk secreted contains nu-
merous globules of pus;  and hence, he objects to  the child being
put to the breast in this state.f
   Chronic abscesses of the  breast  occur chiefly in  scrofulous con-
stitutions, and are  much less frequent than acute  or milk abscesses.
The  matter ought to  be let out, and an attempt  made  to  improve
the general health, by  some of the plans mentioned in the general
observations upon  scrofula.   The state of the  uterine  functions,  in
particular, should  always be inquired into; for  they are often disor-
dered, and then aloetic and steel medicines are indicated.
• Op. cit. p. 26.                   | Id. p. 39< 
148
DISEASES 01  THE  BRCA3T.
  With regard to  diseases of the  breast, arising from peculiar or
specific action, but not malignant, I will first notice

               HYPERTROPHY OF THE BREAST,

Especially that,  which M. Velpeau names glandular, is more fre-
quently met with in the Indies, America, England,  and Germany,
than France.  The principal cause of hypertrophy of the breast is
ascribed by  Sir Astley Cooper to celibacy;  and, according to his
observations, it occurs principally between the ages of  thirty  and
thirty-five.  He mentions a girl, only fifteen years old, whose breast,
of a pyriform shape, and extending over the abdomen, was twenty-
three inches and a half in circumference.  One case is also record-
ed, in which the breast descended to the knees, and weighed thirty
pounds.   Others deem the age of puberty that in which this hyper-
trophy is chiefly noticed.   As  the swelling  is not at first attended
with pain, nor with any serious functional disturbance, its commence-
ment does not excite much attention.   The  menses, however, are
lessened in  quantity, or  are  irregular, or even suppressed.   The
voice is also affected, and patients seem hoarse.
  As the state of  the mamma? is intimately dependent upon that of
the  womb,  M. Velpeau regards  marriage  and pregnancy as the
most likely mode of checking hypertrophy of the breast.  The in-
ternal exhibition of iodine is  also recommended, with iodine baths,
and then rubbing the breast with an ointment, containing either the
ioduret ot lead, the iodide of potassium, or mercury.  A vegetable
diet is preferable to animal food, and a suspensory and compression
are not to be neglected.

                       HYDATED  TUMORS

Were so named by Sir Astley Cooper, who  has described several
forms of them.  Since the expression hydatid would lead us to sup-
pose, that the disease always  consisted, not  of  adherent cysts, but
of detached  globular ones,  endued with separate  vitality, independ-
ent of the texture  in which they are formed,  many surgeons prefer
the term cysts of the breast.
  The tumor  is characterised by  a tendency  to  increase to a con-
siderable size; but it is not prone  to malignant change;  nor  does it
occasion any inconvenience,  except what proceeds from its bulk.
At  first, it feels  entirely solid, but after a time a  fluctuation  can be
distinguished at certain points.   The  tumor is very moveable and
pendulous.  Sometimes the cysts ulcerate, discharge a serous fluid,
and then heal,  or  even become  obliterated.   No local applications
are of any service.  If there  be only one large cyst, and  it be pimc-
tured, sometimes it will not fill again.   The only reason  for remov-
al in this kind of disease, when it becomes large, is to relieve the pa- 
                 CHRONIC  MAMMARY  TUMORS.              14!J

tient from the  annoyance  produced  by its bulk.   All  the swollen
and indurated  parts must be taken away,  for if any small cysts re-
main behind, the disease will recur.   The glands in the axilla are
either free from disease, or only enlarged  from  irritation.  M. Vel-
peau doubts whether the  extirpation of a serous cyst of  the  breast
is ever indispensably necessary.  He  would prefer making a punc-
ture with a  small trocar, emptying the cyst, and then injecting a lo-
tion consisting of 3ij. of the tincture of iodine in each ounce  of wa-
ter.   He has tried the plan, however, only in  one case, but with
complete success.*
   As for sioellings of the breast consisting of globular hydatids, an
incision should be made in them,  and the bag extracted, after which
the part  will heal.   The  disease is characterised by a central fluc-
tuation, a solid circumference, and freedom from tenderness on pres-
sure.  The disease is of an innocent nature.  Dr. Warren describes
one case, in which the tumor weighed  twelve  or thirteen pounds.f

                   CHRONIC  iMAMMARY TUMOR.

   The substance of the female breast  is liable  to a slow kind of in-
duration,—a  swelling  that  grows from its surface rather than from
its interior, and therefore  seems to be superficial, except when it
grows from  the posterior  surface of the breast.   It is exceedingly
moveable; not buried in the mammary gland,  but  only  connected
to its surface; not  generally painful,  nor  tender  when touched; its
growth is slow;  and its weight seldom more than from one to  four
ounces.   It is not malignant, and often remains stationary for years,
and then disperses.  The  disease  seldom occurs  in persons after
the age of thirty.
   The tumor, when taken out and examined,  is loblulated, and at
first view something like the mammary gland itself: it is contained
in a cyst.   The  cause of the chronic  mammary tumor  is generally
sympathy of the breast with the uterus, producing great  determina-
tion of blood to the part;  but  blows and the pressure of stays may
likewise  excite it.
   When the digestive functions are deranged, we may try the com-
pound calomel pill at  night, with the  infusion of calumba and rhu-
barb and carbonate of soda twice a day.   When the uterine func-
tions are disordered, we may prescribe small doses of the blue pill,
with extract of colocynth  and steel  medicines.
   Sometimes the  tumor yields to  the internal and external use of
iodine.  The emplastrum ammoniaci cum hydrargyro is  a common
application.   The  disease  does  not require to be extirpated, nor,
as Sir Astley Cooper observes, is it any impediment to matrimony;
for,  in fact,  pregnancy and suckling rarely fail to make it  disappear.


       * Op.  cit. p. 70.               t Warrea on  Tumours, p. 206.
                           13* 
150
DISEASES OF THE BREAST.
          SCROFULOUS  SWELLINGS OF  THE BREAST

Are occasionally  seen in  young women,  who  have enlarged lym-
phatic glands under the jaw.  In general, there is only one tumor,
and it is exceedingly indolent.   There  is no  disposition to malig-
nancy, and, of course,  it would be  improper  to  have recourse to
extirpation.   The treatment is  like that  of scrofulous  diseases in
general.

              IRRITABLE  TUMOR OF  THE BREAST.

   The breast is sometimes the seat  of severe pain, without any dis-
tinct or perceptible  swelling.  Such an affection might  be called
neuralgia of the breast;  but occasionally, besides  excessive pain in
the part, there  is also a tumor, composed of a structure unlike that of
the gland itself, and which therefore appears to be a specific  growth.
When the  glandular structure is the seat  of it, one or  more of its
lobes become exquisitely tender; and, if handled, the pain will some-
times continue  for several hours,  extending to the shoulder, axilla,
down the arm, arid even to the side of the body.  When the  pain
is most severe, which is  often the case prior to menstruation,  the
stomach frequently sympathises, and the  patient  is troubled  with
vomiting.   The irritable tumor is most  common between the ages
of 16 and  30.
   Sometimes a distinct circumscribed tumor is noticed, highly sen-
sitive to the touch, acutely painful at intervals, more especially just
before menstruation,  very moveable, often not larger than a  pea,
and rarely exceeding the size of a marble.  Although the  disease
may continue for years, it varies but little in size, hardly ever sup-
purating, but  occasionally  disappearing of itself.  In the  general
account of  tumors, I  have already noticed this disease, under  the
name  of painful  tubercle,  as affecting other  parts.  The tumor,
when taken out and examined, is found to be composed of a solid
 semi-transparent substance, with fibres  interwoven with it; but, ac-
 cording to Sir A. Cooper, no large  filaments of a nerve can  be
traced into it.
   Equal parts of soap cerate and extract of belladonna may be ap-
plied; or a bread  poultice made with  a  solution of  the same ex-
tract.   Or  the part may be protected  with a  piece of oil-skin or
hare-skin.   Leeches are proper during the violence of the  pain.
   As internal remedies, we  may  try calomel  with opium,  and
hemlock with purgatives.   If the  menstrual secretion  be interrupt-
ed, the mistura fern comp., combined with aloes, may be prescrib-
 ed.
   The breast is also liable to the greater number, if not all  the
varieties, of tumors noticed in our first  section. 
WOUNDS  OF THE  BELLY.
151
      THE  ECCHYMOSE DISCOLORATION OF THE BREAST

Is a morbid change, sometimes  occurring in  young women at the
time  of menstruation, preceded  by severe  pain in the breast and
arm.   Velpeau notices its occurrence also sometimes in women ar-
rived  at the critical age.   The extravasation of blood makes its ap-
pearance as a large spot, with smaller and less conspicuous ones in
other places.  In general, it gradually disappears after menstruation.
According to Sir Astley Cooper's views, the indications are, 1st,
to render the menstrual discharge more regular, by means of steel
medicines;  and,  2d, to  support  the strength by means of  sulphate
of quinine, given with infus. rosse comp.   The best  local  applica-
tion  is the alig.  ammon. acet. with  spirit of wine, five  ounces of
the former to one of the latter.   M.  Velpeau does not consider any
active treatment usually requisite, as  the discoloration and  pain al-
most always subside of themselves in a  fortnight or month; but,  if
a contrary case  presented itself, he would-try one general bleed-
ing, leeches to the  breast, a discutient lotion, and purgatives and
emmenagogues.
   With respect  to the third class of diseases of  the  breast, or the
malignant, it comprises scirrhous and medullary cancer, the nature
of which has been treated of in the first section of this work.
                WOUNDS OF THE  BELLY

Are divided into two principal classes: in one, the solution of con-
tinuity is confined  to the integuments, muscles, &c. exterior  to the
peritoneum; in the other, this membrane is penetrated, and frequent-
ly some of ihe viscera.   Wounds, which do not extend through the
peritoneum, are not materially different from those of ordinary tex-
tures, and are to be treated on  principles  applicable to woui.ds in
general.   However, if  the  injury penetrate more deeply than the
integuments, the parietes of the abdomen generally remain weaken-
ed at the  part;  and, firm as the cicatrix may  appear, if it be  not
supported with a bandage, it is liable to become the seat of a hernial
protrusion.'1   Severe contusions of the  skin  and muscles  of the
belly are also sometimes followed by such  an incapacity of rcsist-
  * Ilirherand, Nosogrophie Chir. t. iii. p. 322. ed. 2.  Schmucker relates a case,
which follow  d puncturing Hti abscess of ihe abdomen with a lancet, Vermischte Chi-
rurgische Schriften, band. i. p. 797.  See also a case by Wardrop, in Sir A. Cooper's
work oil Crural and Umbilical Hernia, p. 60. 
152
WOUNDS OF THE BELLI'.
ance in them,  that they yield to the pressure of the contained parts,
and a particular kind of hernial tumor is the consequence.
  A spent ball, striking  the  belly, may rupture  the rectus  muscle
and  aponeuroses  of the abdominal muscles, so  as to produce at
once a protrusion of the viscera; while the integuments, on account
of their greater elasticity, continue unbroken.*   In other examples,
the ball,  in its rotation over the circumference of the abdomen, not
coming against any hard projecting part,  depresses the parietes of
the belly, and produces deeper mischief amongst  the viscera, suc-
ceeded by inflammation, a copious effusion of bloody serum  in the
cavity of the peritoneum, and other fatal effects.f  In a case  that
had a favorable issue, a cannon  ball carried away the  integuments,
a piece of the left os  ilium, and the attachments  of the broad mus-
cles of the  belly, exposing  a  part  of the sigmoid flexure  of the
colon4
   Sometimes, in consequence  of punctured wounds,  or violent
blows, matter forms in the tendinous sheath of the rectus muscle;  and
when the abscess bursts, or is opened, several pints of pus are unex-
pectedly discharged.   The  nature of  this case  should be remem-
bered, as there is frequently  no change of appearance in the integu-
ments, denoting either the suppuration, or its extent.   Such an ab-
scess ought always to be opened early, and in a depending situation.
The same practice is  advisable, when  purulent  matter collects be-
tween the layers of abdominal muscles, or between these muscles and
the fascia transversalis, and the peritoneum.
   Except when  a wound of the belly is free and  direct, attended
with protrusion of the bowels, or the escape of feces, chyle, fetid air,
bile, &c, the fact of its having penetrated the cavity  of the abdo-
men is generally somewhat obscure. Authors do,  indeed, advise us to
compare the direction of the  stab with the ordinary thickness of the
abdominal parietes at the wounded part, and the breadth  of the wound
with that of the  weapon with which the injury has been  inflicted.
When the instrument has entered perpendicularly at a place where
the parietes are thin,  and when, notwithstanding  the narrowness of
the end  of the weapon, the  division  is  rather broad,  it  is inferred
that the wound is of the penetrating kind.  This mode of judging,
however, must generally be fallacious, on account of the frequent im-
possibility of learning the exact direction of the thrust, or of obtaining
a s:ght of the instrument.   Also when a probe will pass perpendicu-
larly into the wound for a certain distance, it is concluded, that  the
injury extends into the abdominal cavity.   But it must not be posi-
  * Larrey, Mem. de Chir. Mil. t. iii. p. 332.
  t Op. et vol. cit. p. 334.
  % See in Hennen's Mil. Surgery, p. 452., a case, in which nearly all the anterior
p.irietes of the belly  were torn away, leaving the lacerated peritoneum exposed.  The
iijjary was not immediately fatal. 
WOUNDS OF  THE BELLY.
153
tively  inferred,  that  the  wound does  not  penetrate  because  a
probe cannot be thus introduced;  for its passage may be stopped by
the several layers of muscles not having exactly the same situation
with respect to each other which they had at the moment of the in-
jury.  In short,  unless the wound  be straight, a probe can hardly
be made to follow its course.   The local symptoms, then, of a sim-
ple  penetrating wound  are  frequently not  to be  depended upon,
and ihe employment of  probes and injections for  ascertaining the
point is more likely to do serious  harm then real  good.  Nor can
certain information always be deduced from a consideration of what
may be called the general symptoms; a small, feeble, contracted
pulse; pallid countenance; cold extremities; great and sudden de-
bility; hiccough; vomiting; and spasms.  Several of these effects
frequently take place in irritable, timid,  nervous  subjects, without
any parts  being injured in addition to the skin and muscles; and they
are frequently absent when the  weapon has actually entered the pe-
ritoneum.   I am far from meaning to  say, however, that such indis-
position is to be disregarded; on the contrary, it seems to me,  that
particular attention ought to be paid  to the symptoms in question;
because, if they do not soon subside, there are then strong grounds
for suspecting something more than  the effects of a common superfi-
ial wound on an irritable, timid subject.  But, in the beginning, unless
the  wound be large, or a protrusion of the viscera,  or a discharge of
bile, chyle, or feces, take  place,  there  is generally a degree of un-
certainty  with respect to  the depth  of the  injury.  At  the same
time,  it is not  to  be concluded that the wound  does not penetrate
because no protrusion nor extravasation happens;  for a narrow  stab
may extend into the abdomen,  even  amongst the  viscera, without
giving rise to either of these accidents.
   There  is in these cases a class of symptoms which Ritchter* and
other writers denominate particular, from their evincing what bow-
els are wounded; as, for instance, bloody urine,  when the kidneys
and urinary bladder are injured; vomiting of blood, when the stom-
ach is pierced; discharge of blood with the feces, when  the large
intestines  are wounded.   Symptoms like these must of course throw
considerable light on the nature of the accident.
   With regard to our not  being always able to  pronounce whether
a wound penetrates the cavity of the  belly or not,  the want of pre-
cise information on this  point is of little practical  importance;  for,
if the case be not complicated with any urgent symptoms, the treat-
ment should obviously resemble that of a simple wound.
   The principal  danger  of penetrating  wounds of the belly partly
arise from internal haemorrhage, or  extravasation of the contents of
the viscera; but in a still greater degree, from the strong disposition
* Anfangsgr. der Wundarzn. b. v. p. 7. 
154
WOUNDS OF  THE BELLY.
of the peritoneum to inflammation.   With the exception of  persons
who die instantly or in a few hours, from internal bleeding, &c, nine
tenths of those who die from penetrating wounds of the belly, are
cut off by peritonitis.   They who perish with extravasation of the
contents of  the bowels,  also die in  fact from peritonitis,  which is
generally excited  partly by the injury, and partly by the irritation of
the effused matter.   Many authors represent the danger of a pene-
trating wound of  the belly,  as principally arising from the entrance
of air into the cavity of the  peritoneum.   But,  according to my
ideas, it is the wound itself that excites the peritonitis, by which the
patient is destroyed; and the same  fatal inflammation would come
on with equal frequency, were the wound entirely excluded from the
air.   The cavity of the  belly is always so  completely occupied by
the viscera, that the whole  inner surface of the peritoneum is  con-
stantly in close contact with them, and, therefore, the air cannot so
easily enter  within that membrane as some writers seem disposed to
believe.

WOUNDS IN WHICH  THE  VISCERA PROTRUDE,  BUT ARE UNIN-
                            JURED.

  When a portion of intestine or omentum protrudes, the sooner it
is returned,  the more effectually will the irritation,  arising from its
exposure and constriction be prevented.   Fomenting the protruded
bowels, as is sometimes  recommended, would be absurd; for what
application can be so congenial to them,  as  the natural warmth and
moisture of  that cavity into  which they ought to be immediately re-
duced?  And is it,possible  to suppose, that the efficacy of any ar-
tificial fomentation will make  amends for the harm,  resulting from
continuance of the bowels in a state of exposure and constriction?
In order to  promote  the reduction, the muscles of the abdomen
should be relaxed; but, whether we  ought to waste any time in giv-
ing clysters  to empty the large intestines, previously to attempting
to return the parts, is a question,  on which I entertain the same sen-
timents as those delivered on the subject of fomentations.  The me-
sentery is always  to be returned before the intestine;  and the intes-
tine before the omentum; but the last protruded portion of each of
these  parts ought  to be  first reduced.  In the reduction, care must
be taken that the  bowels are completely returned into the abdomen,
and are not  pressed  between the  layers  of the abdominal muscles,
or into the sheath of the rectus muscle.
  When the distention of the protruded  intestine  with air or feces
creates a difficulty of reduction, its contents may frequently be gra-
dually pressed into  that portion of the intestinal canal which is
within the abdomen, and the gut may then be returned.   But, if this
plan were  attended with difficulty, I should prefer dilating the wound
to much handling of the  bowel. 
WOUNDS OF THE BELLY.
155
  When the protruded bowel is distended with air,  Pare and others
recommend making small punctures in it wilh a needle,  so that the
air may escape, and the intestine collapse.   This proposal is justly
rejected from  modern surgery, both on the  grounds of  danger and
inefficacy.   The small apertures made with a round needle will not
discharge the air; for they are closed by the mucous coat*, and the
making of larger punctures,  as suggested by Desaultf,  would be far
more dangerous  than dilating the  wound.   When  it  is absolutely
necessary to enlarge  the wound,  the delatation should be made in
a direction which will not endanger the epigastric artery; and, if pos-
sible, parallel  to the muscular fibres.
   When the protruded intestine is already inflamed, its immediate
reduction is,  beyond all  dispute,  the right practice.    Even when
the inflammation is severe,  the reduction of the part without delay,
and the  employment of antiphlogistic means, will often prevent gan-
grene.   The  dull, brown, dark-red color of the protruded  intestine,
may induce the  practitioner to  suppose, either that  it is already gan-
grenous, or that grangrene is inevitable, and,  consequently, he may
delay returning it  into its  natural situation.   But, notwithstanding
this suspicious color of the  intestine, its firmness will  evince that it
is not  a state  of gangrene, and,  therefore, its  immediate reduction
ought  to be put in practice.   The recovery of a portion of intestine,
so circumstanced, is always a matter of uncertainty;  but  the  pro-
priety of speedily replacing it in its natural situation is a thing  most
certain.   In case it should  mortify, after  being reduced,  all hopes
of the  preservation of life ought not to be abandoned.
   When the omentum protrudes, and is strangulated by the narrow-
ness of the opening,  it soon contracts  adhesions.   Richerand has
recommended us to cut off  all  this  membrane  which  exceeds the
level of  the integuments, and not  to trouble  ourselves  about the re-
mainder, which, he asserts,  will act like  a stopper, and hinder  a fu-
ture hernia.    If adhesions had already been formed, this  practice
would, perhaps, be  the best, but  under  other circumstances, if the
omentum were sound and free  from constriction, it should  unques-
tionably be reduced without delay.  In cases where this membrane,
besides protruding, is in a gangrenous state, certain w riters authorise
the excision of the dead part,  and the reduction of the rest,  each
of the bleeding vessels having been first  tied with a small silk  liga-
ture.   It will  be found, however, that whenever the omentum has
been out so long as to slough, adhesions  within the wound  have had
time to form; an event which  would embarrass the operator, and
constitute a decided prohibition  to the  attempt.   The reduction
having been effected, the patient  is  to be laid upon his back,  with
the thighs somewhat raised or bent, and he must strictly avoid mak-
* See Travels on Injuries of Intestines, &c. p. 176.
t Trait dos Maladies Chirurg. torn. ii. p. 135. 
156
WOUNDS  OF THE  BELLY.
any exertion, lest he bring on another protrusion.   The wound is
then to be closed with  adhesive plaster, the uniting bandage, or a
suture.  Sewing up wounds of the belly made a long subject, in all
the  old  works  on surgery,  under the appellation  of gastroraphe,
which was nothing more than a quill-suture, practised  by introduc-
ing  the needle through both lips of the wound from within outwards,
in order to avoid all risk of pricking the bowels.  In Pibrac's *dis-
sertation on the  abuse of sutures, cases are related which satisfacto-
rily prove, that the majority  of penetrating  wounds of the belly
may be healed  very well without  it;  and if we wish  for still  more
decisive proofs  of the fact,  we may find them  in  accounts of the
Caesarean operation, the extensive wound of which has frequently
been healed by common means.   But, though sutures are not  nec-
essary for  all wounds of the  belly, they may be useful  under partic-
ular circumstances:  for instance, were  the wound of a certain size,
they might be indispensable to  prevent the protrusion or exposure
of the bowels.

   CASES WITH   INJURY AND PROTRUSION OF  THE VISCERA.

   Penetrating wounds, attended with protrusion of  the intestines or
omentum, are always to be regarded as  dangerous  cases;  but  the
danger is much more serious, when a portion of the intestine not on-
ly  protrudes, but  is wounded.   Under  such circumstances,  we
have the authority of numerous writers on surgery, as a  sanction of
the practice of sewing together  the edges-of the wound  in the bowel;
the true utility of which practiee, however, is now a disputed point.
Even the advocates of  sutures  here  differ exceedingly, both as to
the precise object in view, and the way of making the stitches.  Some
advise only one  stitch ,to be made (frequently only through the me-
sentery) ; and they employ the ligature chiefly with the view of con-
fining the injured bowel near the external wound, so that, in the event
of any effusion, the matter  may readily find its way outward.   Other
writers wish  to remove  the possibility of  extravasation by applying
numerous stitches,  and attach little importance  to the  plan of using
the ligature principally for  the purpose of keeping the intestine near
the external wound.
   When the  wound of a bowel is so small, that it is closed by  the
protrusion of the villous coat, the application of a suture must evi-
dently  be needless.   Supposing  the  breach  in the intestine, how-
ever, to  be somewhat larger, so as to be capable of letting the feces
escape, what practice ought we to follow?^As Sir Astley Cooper
was operating upon a strangulated hernia, an  aperture, giving  issue
  * See Mem. de l'Acad. de Chir. torn. Hi. 4to.  Other cases of similar success may
be perused .n numerous works; Journal de Me'decine, torn. lxxi.; Duncan's Medical
Commentaries, vol. x ; Philosophical Transactions, vol. xvi. &c. 
WOUNDS OF THE BELLY.
157
 to the intestinal contents, was discovered in a portion of sound bowel,
 just when the part was about to be reduced.   The operator, includ-
 ing the aperture in his forceps, caused a fine silk ligature to be car-
 ried beneath the point of the instrument, firmly tied  upon  the gut,
 and the ends cut off close to the intestine.  The part was  then re-
 placed, and the patient recovered.   Mr. Travers, who has related
 this fact, approves of the plan  of cutting away the  extremities of
 the  ligature, instead  of leaving them  hanging out of the  external
 wound; for the remnant always finds its way into the  intestine, and
 is discharged by  stool, without the slightest inconvenience.*
   We are next to consider the case, in which the protruded bowel
 is still more  extensively, or even totally, divided.   Here the admir-
 ers of the needle  have found ample scope for their ingenuity; and
 since very few of them have met with cases exactly of this  descrip-
 tion in tho human subject, they have made a variety of experiments
 on animals,  in order  to determine  the right mode  of treatment.
 Some of these reports are  favorable to  the  practice of sewing  up
 the wounded bowel.   Ramdhor  is stated to have actually cut off a
 large part of a mortified intestine in  the human subject, and to have
 joined  the sound  ends together, by  inserting  the upper within the
 lower one, and fixing  them in this position with a suture; the  liga-
 ture being also employed to keep them near the external  wound.
 The  patient  recovered, and the feces afterwards passed entirely the
 natural way.f  About a year after the operation the patient  died,
 when the anatomical  preparation of  the  parts  was sent to Heister.
 They were preserved in spirit of wine, and exhibited, according to
 this last author, a union of the two ends of the bowel  and their con-
 solidation with a part of the abdomen.   Now, it has been reasonably
 questioned, whether the union here spoken of ever really happened.
 When the  upper end of the bowel is introduced into  the lower, the
 external surface of the  former is put in contact with the inner one
 of the latter;  a serous membrane is placed in contact with a mucous
 one.   These heterogeneous structures are not disposed  to unite.
 The  mucous membrane, when  inflamed, more readily secretes a
 kind of mucus, which must be au invincible  obstacle to adhesion.
 In the case related by Heister, the invagination was probably main-
 tained by  the  union of the intestine with the  corresponding part
of the abdominal  parietes.   Several experiments on  living  animals
 tend  to prove, that the mucous membrane will not unite with  the
external  peritoneal  coat.  If this  be  a fact,  it  is of  course  a
strong argument against  repeating Ramdhor's practice.   Another
objection is,  that the upper end of the  bowel can.iot be put  into the
lower one, unless it be separated  from  a part of (he mesentery, and
•Inquiry into the Process of Nature in repairing Injuries of the Intestines, &c.

t I taller, Disput. Anat. vol. vi.; Obs. Med. Miscell. 18
 VOL.  n.                   14 
158
WOUNDS  OF THE  BELLY.
a division of the mesenteric arteries would cause a dangerous bleed-
ing.  In vain did Boyer tie seven or eight of these vessels; his pa-
tient died with an extravasation in the  abdomen.*   The difficulties
encountered by Moebius and Dr. Smith in their attempts to repeat
this experiment on  animals,  are related  in  ray Dictionary, and I
need not, therefore, expatiate upon them.   In  short, experience is
decidedly adverse to Ramdhor's practice, either in its original form,
or modified by the ingenious introduction  of cylinders of isinglass,
pasteboard, &c.   Flajani  tried the artifice on several patients under
his care in the hospital at Rome,  but death was invariably the con-
sequence, f   I am of opinion that Mr.  Travers  deserves  the thanks
of the profession, for  the  attention  and talent  with which he has
investigated the subject before us; but, with respect to the question
of sutures, I apprehend that he has gone  too far,  when he declares
that, in order  to  avoid abdominal  effusion,  the  suture  employed
should be such as will secure the  absolute  contact of the  everted
surfaces of the divided intestine.:):
   When the  intestine has been  completely divided with a cutting
instrument,  Scarpa§ is decidedly of opinion, that  Ramdhor's ope-
ration cannot be undertaken  with any probability of success.  But,
setting out of the question  this  bold method, at once so amusing and
captivating  to  the inexperienced  student, this  eminent  professor
offers a variety of arguments against  sewing the intestines  at all, and
asserts that  in all cases of penetrai'ng wounds  of the abdomen, at-
tended with  injury of the intestine, whether the canal be opened lon-
gitudinally  or  transversely, a  suturz is always  not merely  useless,
but even dangerous and fatal.   In whatever manner it  is practised,
says he, one cannot avoid the  evils which must originate from the
punctures, however  few,  and  from  the  passage  of the  ligatures
through the  coats of the intestine;  a part endued with exquisite sen-
sibility, and whose external tunic is  much disposed  to  inflame, and
rapidly  to communicate the inflammation to all the other  abdominal
viscera.   It has  (says Scarpa)  been unfortunately  proved, by the
experience of several ages, that,  in  most of the cases in which the
intestine has been stitched in penetrating wounds  of the  belly, the
patients have died in the greatest agony.   If a few escaped the dan-
gers of this  operation, it was only because in them the stitches soon
cut their way out, and were voided with the feces, which continued
to escape from the wound  until it was entirely healed.
   All surgeons of experience,  and particularly those of large hos-
pitals,  have often seen wounds  of the right or left  iliac  region ac-
  * Richerand. Nosogr. Chir t. iii. p. 345. &c, edit. 4.
  t Collezioned'Osservazioni, ,Vc. di Chirurgia, tomo iii. p. 60 8vo. Roma, 1802.
  t Inquiry into the Process of Nature in repairing Injuries of the Intestines' d  121
and p  134.                                                  ' *'
  § Sull' Ernie Memorie Anatomico-Chirurgiche; mem. iv. fol.  Milano 1809. 
WOUNDS OF THE BELLY.
159
 cornpanied with injury of the great intestine.   They may also have
 noticed in these examples, that,  after the subsidence of the  local
 and general  inflammatory symptoms,  the  wound  still continues to
 discharge feces for a certain time; but that afterwards it contracts,
 and the excrement resumes its usual course.   These wounds almost
 always heal* completely: first, because  the adhesion of the  large
 intestine  to the  parietes of the  abdomen prevents the  feces from
 being  extravasated in the cavity of the peritoneum; and, secondly,
 because the ample capacity of the same  bowel always presents a
 ready passage for the feces,  notwithstanding the  progressive, and
 sometimes quick, closure of the external opening.
    If,  in the instance of a penetrating wound  of the belly, attended
 with injury of the small intestines, it were in the  surgeon's power
 (as indeed it is) to return the  bowel into the abdomen,  so  that the
 opening in it may exactly correspond to the wound  in the abdominal
 parietes, there could not be a  doubt  of  its  quickly acquiring adhe-
 sions  to  the  peritoneum, which  lines the part  around the  internal
 orifice of the external wound.   Hence, the feces would readily es-
 cape from the outer wound, and  at length  the artificial  anus would
 close, and the feces resume their natural course, just like what hap-
 pens in wounds  of the large intestines.   The  narrow diameter of
 the small  intestines would  not make an insurmountable  obstacle to
 the passage of the feces, if these were, as  they usually are, in  this
 part of the alimentary canal, in  a sufficiently fluid state; and be-
 sides  (as Scarpa observes), is it not proved  by experience, that they
 resume their natural course, after the cure of an artificial anus, even
 when  a considerable noose of the small intestines has been destroy-
 ed by gangrene, and when the two  ends form by their reunion a
 very acute angle?  Scarpa then feels no hesitation  in admitting the
 possibility of curing wounds of the small intestines, without having
 recourse to a suture.  It would  not, he says, be difficult  to  quote
 examples of such cures; and one is  related,  which  fell under his
 own observation.   He  afterwards  describes the incessant  pressure
 made by the abdominal muscles and diaphragm upon all the viscera
 as  the cause which makes  the  wounded intestine enter the  external
 wound, and soon adhere to its  edges, instead of quitting  it.   When
 these  adhesions  are  formed, all  danger of extravasation  is  over.
 He observes,  that one should neglect no remedies, internal as well
 as  external, which  may be of use in moderating the patient's suffer-
 ings, diminishing  the impetus of the circulation,  and bringing the in-
 flammation down to the degree suited to the formation of adhesions.
 He recommends  keeping the external wound open, with the  same
 precautions, and  according to the same indications, which are to be
 attended to in the treatment of an artificial anus.   The principal ob-
ject of these precautions is to let  the treatment be such, that the
• See Larrey'* Mem. de Chir. Mil. t. ii. p. 161. 
 160               WOUNDS OF THE BELLY.

external wound may only diminish in proportion as the  evacuation
from the lower part of the intestinal canal increases.
   The very nature of the process, by  which  the reparation of
wounds or the bowels is effected, is a weighty argument against the
employment of a suture. In their cicatrisation, they follow quite a dif-
ferent course from that of simple wound of the skin, muscles, or any
other parts of the body. Their edges never become immediately ap-
plied to each other, and therefore, strictly speaking, they do not reu-
nite.   Their cure is altogether completed through the medium of the
surrounding parts; that is say, by the adhesions which the  intestines
contract with the great sac  of the peritoneum lining  the cavity of the
abdomen, or with the productions ofihis membrane, which  compose
the external covering of the greater part of the viscera.*
   Even from the description which  Mr.  Travers has given of the
process of reparation, in the cases where sutures are employed, we
may conclude,  that the stitches can  be of little  service;  for, says
he, " the  action of the longitudinal fibres being opposed  to the arti-
ficial connection, the sections mutually recede as the sutures loosen
by the process of ulcerative absorption."]  Unless,  therefore,  it be
allowable to suppose, not  only that  the divided  portions  of bowel
can be sewed together  so  closely and accurately at every point as
to remove all possibility of effusions of its  contents, but  that  this
can  also  be done  without risk  of  exciting inflammation of  the
bowel, thus handled, dragged, and stitched, I must fully agree  with
Scarpa, respecting the impropriety of thus boldly sewing up wounds
of the  bowels with as little scruple as a hole in a  glove.
   In some former editions, I have said, that if a case were to  pre-
sent itself, in which a protruded intestine  were extensively cut, or
its whole  diameter completely divided, I should venture to make a
single stitch with a small needle and a piece  of fine silk.   But sub-
sequent Teflection and information make me doubt whether this lim-
ited employment  of the  needle would  be necessary; and if not
necessary, it would undoubtedly be improper.  The following case,
which, as well as Ramdhor's memorable experiment, is  at variance
with another statement,  that wounds amounting to a  direct division
of the  canal are irreparable, and therefore invariably fatalj,  furnishes
an unequivocal  proof, not  only that an intestine may be completely
cut through, and  the injury not always be  fatal,  but that the cure
may be effected without any stitching whatever of the bowel.   At
the assault of Cairo, in 1799,  M. N-----  was  struck  by a  ball,
which  divided the muscular parietes  of the abdomen, and a portion
of the  ileum.   The two ends of the  bowel  protruded, were separ-
ated from each other, and  very much distended.   The upper end
* See ease recorded by Littre in Acad. Royale des Sciences, an. 1705.
t Inquiry into the process of Nature in repairing Injuries of the Intestines d 28.
% Op. cit. p. 133.                                           r 
WOUNDS  OF THE  BELLY.
161
was everted, its contracted edge strangulating the intestinal tube, as
the prepuce does the penis in paraphymosis.   The progress of the
contents of the bowel being thus obstructed, they accumulated above
the constriction.   Larrey  began with making four small incisions in
the constricted part  of the intestine;  he then passed a ligature
through the portion  of mesentery corresponding to the two  ends of
the bowel;  reduced them  as far  as the edge of the  opening, which
he took care previously to enlarge;  and, having dressed the wound,
he awaited events.  Without detailing the subsequent particulars of
the case, suffice it to say, that in a few months it ended in a perfect
recovery.*
   It is curious that  Flajani,  who has so decidedly reprobated Ramd-
hor's practice, and  mentioned facts against it from  his own experi-
ence,  should recommend  stitching a wounded  and protruded bowel
 in any manner;  for, with the exception of his unfortunate  trials of in-
serting one end of the bowel into the other, in the cases which occurred
 in the hospital at Rome, he  records only two instances  in which he
 stitched the intestine, and, in both these, the bowel became gangren-
 ous, and the patients lost their lives.f  We may therefore infer, with
 Mr. John Bell, "that if there be a work of supererogation in surgery,
 as I believe there are but  too many, surely this of sewing an intes-
 tine is one. "|
    Every reflection, then, which I can  make  on this subject leads
 me to adopt Scarpa's sentiments in relation to sutures, and the in-
 dications, which should be fulfilled.   The chief indication, and that
 on which the  patient's  safety mainly  depends, consists in keeping
 the external wound open, in order that  the feces may find a ready
 outlet.  The wounded bowel soon contracts adhesions to the inner
 lips of the wound  of the belly, and then  we have  nothing to fear
 from an extravasation of intestinal matter in the cavity of the peri-
 toneum. Afterwards, in proportion as the feces resume their natur-
 al course, the external wound is to be allowed to diminish, and en-
 tirely heal up.§
    In  every instance  of a penetrating wound  of  the abdomen, at-
 tended  with injury and protrusion of a portion  of the intestinal ca-
 nal,  if the patienttbe not  already in a hopeless  or dying state, from
 internal hemorrhage and other lesions, the displaced part is to be re-
 duced,  whatever  we may  choose to do in respect to the free or lim-
 ited employment of stitches, or their absolute  rejection.   The re-
 duction should be performed as  speedily as possible, before the bow-
 el has suffered  much from exposure, constriction,  &c, and also be-
 fore any adhesions  have  formed at the inner  orifice of the external
  * Larrey, Mem. de Chir. Militaire, t. ii. pp. 160, 161.
  t Collezione d'Osservazioni, &c. di Chirurgia, t, iii. p. 35—41.  In one case, the
protruded bowel was a po,tion of jejunum; in the other, a piece of colon.
  X Discourses on the Nature and Cure of Wounds, edit. 3d, p. 320.
  § Scarpa sull' Ernie Memorie Anatomico-Chirurgiche; mem. 4.
                           14* 
162
WOUNDS OF THE BELLY.
wound; adhesions which would make the reduction of the protruded
part irnracticable.   Of course when the wound  is so  small,  that
the reduction  cannot be effected without handling and bruising the
bowel immoderately, it ought to be carefully enlarged with a curved
bistoury, guided on a director.  Indeed, according to Scarpa's prin-
ciples, one  would suppose that the wound, if not free, should al-
ways be dilated, as by this means the ready escape of any extrava-
sated matter would be insured.   The rest of the  treatment consists
in antiphlogistic measures, more  especially copious and repeated
venesection, with the view of counteracting  the danger of peritoneal
inflammation.   With respect to  the dressings, they  cannot be too
light, simple, and  superficial, except when  the stoppage of evacua-
tion in the natural  way, and the issue of the intestinal contents from
the breach in the bowel,  are such as to lead us to adopt particular
means  for hindering  a premature closure  of the external wound.
The tepid water dressing is one of  the best.
   The  pressure of the elastic bowels, and of the diaphragm, and
abdominal muscles, not  only frequently presents  an obstacle to the
wide diffusion of extravasated matter,  but  often propels it towards
the external wound.*   We can conceive no power capable of over-
coming the  resistance  so  produced, to the extensive dispersion of
extravasated fluids in the cavity of the abdomen.   Numerous cases
are on recordof persons being  stabbed,  or shot through the body,
without any effusion in  the  abdomen,  or other  very serious conse-
quences.  In some few of these instances, the bowels,  perhaps, might
have eluded the ball, or point of the weapon; yet it is highly probable
that, in most of them, the bowels were injured,  and that an extra-
vasation of the intestinal matter was  impeded by the  pressure to
which  I have referred.  In many of the cases, the  intestines were
known to be wounded.f

PENETRATING WOUNDS,  ATTENDED WITH INJURY  OF  THE  VIS-
                  CERA, BUT  NO  PROTRUSION.

   A wound of the intestines is indicated by the discharge of blood
with the stools, and sometimes by the escape of fetid air, or of in-
testinal  matter from the external wound.  Such an injury, however,
when the wounded bowels lie concealed in  the belly,  does not al-
ways admit  of being immediately  known  with certainty.  In the
majority of  examples, there is at first no escape either of air,  or of
  * On this subject, I would particularly recommend the reader to consult two essays
by M. Petit le Fils, one entitled " Essai sur les Epanchemens et en particulier sur les
Epanchemens de Sang;" the other, "Suite de I'Essai sur les Epanchemens,"  in
Mem. de l'Acad de Chir. torn. ii. and iv. 12mo.
  t Recoveries are recorded in Wiseman's Surgery, p. 371.   CEuvres de Par', liv.
x. chap. 35.; La Motte, Traite Complete de Chir. Albucasis, lib. ii. cap. 26; Ravaton,
Traite des Playes d'Armes-a-Feu, chap. 6., &c. &c. 
WOUNDS OF THE BELLY.
163
the contents of the bowels, from the  external wound;  the quantity
of blood voided  per anum may be  inconsiderable; and  however
this may be, none at all  will generally be discharged downwards,
until a certain time after the accident.  Wounds of the small intes-
tines, especially of the duodenum and jejunum, are indeed usually
followed by great  anxiety, paleness of the  countenance,  syncope,
cold perspirations, and  a small, intermitting, tremulous pulse;  but
these symptoms are far from being unequivocal, and they cannot be
said to furnish  any positive information, because  a superficial  cut,
or unimportant stab,  frequently causes similar  indisposition in  sub-
jects of  nervous, irritable, or timid habits.  Our inability, howev-
er, to say positively in every case, whether  the bowels are injured
or not, is of no'practical importance; because, when  the nature of
the accident is not clearly manifested by some peculiarity or severi-
ty of the symptoms,  the case ought to be  treated on common  anti-
phlogistic  principles; and also, when circumstances leave not  the
smallest doubt of the  intestines  being hurt,  the same treatment is
the only rational plan.   Wounds of  the  small  intestines  are more
dangerous than those of the  large, and the nearer the injury is  to
the  pylorus, the greater is the risk.   Such cases are also much
more  frequently than injuries  of the  large  intestines  the cause of
extravasation.   In the latter examples, the symptoms are generally
milder, and either  the  passage of the intestinal contents outward
through  the wound more easy and certain, on account of the  bow-
el being more fixed than the rest of the intestines; or  their passage
towards the anus more ready, by reason of the greater capacity of
the coeeum, colon, and rectum.
   There are several other facts,  highly interesting, and  absolutely
necessary to be remembered in relation to wounds of the bowels: my
limits, however, oblige me to pass over the rest of this subject  with
as much brevity as possible; for which, the fuller account in  mv
dictionary  will also afford a just excuse.   Were  it  not  for  these
considerations, 1 should have felt  myself obliged  to enter  into ex-
planations of the particular appearances presented, as well by punc-
tured wounds, as by transverse and longitudinal cuts in the intestin-
al canal; and to comment on  the circumstance of small  punctures
being obliterated by the protrusion of the  villous coat.   I should
also have had to point out the results  of Mr. Travers's experiments
on dogs, proving that, in these animals, a  division of  the small in-
testine  as  far  as  the mesentery is always  fatal; that generally in
wounds of the intestinal canal,  the retraction, immediately follow-
ing the injury, is a chief obstacle to its reparation; and that longi-
tudinal wounds of the bowels are more easily repaired than such as
are  transverse.  This tendency of the  two portions  of  a divided
bowel to recede from each  other,  tends  to show, that  the  only
mode of spontaneous reparation consists in the formation of an ad-
ventitious canal, by the encircling bowels and their appendages. 
164
WOUNDS OF THE BELLY.
  In the preceding remarks, I have adduced many arguments, cast-
ing doubt on  the propriety of sewing  up a wound  in a protruded
bowel; but, when the injured intestine lies  in the cavity of the belly,
the rashest surgeon, the greatest admirer  of needles, would never
think of ripping open his patient for the sake of performing so cru-
el and  fatal an experiment.  In  fact, as I have already  stated, we
rarely know at first that the bowel is injured;  for extravasation,  as
will be presently related, is not the most  usual consequence of a
wound of an intestine: when  it  happens,  the  extravasated matter
does not always flow out of the  external  wound, and  indicate the
nature  of the  accident;  and,  if an  extravasation should  become
manifest in a later stage of the case, it would then be impossible to
get at the wound of the bowel, on stccount of  the adhesions, which
generally form with suprising rapidity.   Even  if the wound of the
intestine were known to ex;st directly  after the receipt of the inju-
ry,  and a suture were not objectionable, on grounds already detail-
ed, it could not  be applied without enlarging the external wound,
searching  for the wounded bowel,  and drawing it out of the cavity
of the  abdomen.  By these steps, a wound, not at first  essentially
fatal, might be so altered for the  worse, as to leave no possibility of
recovery.  When an intestine is first found to be wounded,  from
the occurrence  of extravasation,  a day or  two  after the injury,  a su-
ture is  entirely out of the question, as by  this time the part is en-
tirely fixed in its situation by the adhesive  inflammation, —that sal-
utary process, which  also circumscribes  the  effusion, and  throws
out an  effectual partition between the extravasated fluid and the gen-
eral cavity of the peritoneum.
  When the wound of the intestinal canal is  situated in the' abdo-
men, closely behind the external wound, a suture is also unnecessa-
ry,  because, if care be taken to keep that  opening from closing too
soon,  the contents of the gut will be  discharged  outwardly, and
there will be no reason to fear their  diffusion  among  the  viscera.
Nor is  the wounded bowel at all likely to  slip away from the  outer
wound, if the  patient be kept duly  quiet for  a few  hours,  after
which the adhesions render a  change in the situation of the bowel
quite impossible.
  In a penetrating wound of the abdomen, caused  either by gun-
shot or a pointed  instrument, if no protrusion of intestine take
place,  the lancet, abstinence, and quietude, should be our chief de-
pendence.   In  short, as  the  main danger is inflammation of the
peritoneum  and  bowels,  the  rigorous  adoption of  antiphlogistic
treatment is indispensable.  Pain and  tension must be relieved  by
leeches,  fomentations, and  the  warm  bath;  and if any purgative
medicine  be given (which, however, I think should never be  done
before time has  been afforded for the formation of adhesions), it
should be of the mildest  description possible.  Castor oil  is per-
haps the safest  which can be employed.  In  these cases,  indeed, 
WOUNDS OF THE BELLY.                165
clysters are generally to be preferred to any other means of empty-
ing the bowels.   By  the  simple observance  of an  antiphlogistic
plan, wounds, in which several folds of the bowels were hurt, have
been happily cured.   Authors abound with  instances of this kind.
One related  by Littre, I have already referred to in  this chapter.
Garengeot and La Motte record others; and Dr. Hennen has seen
several: one  was  the  recovery of a soldier, who had  been shot
through the  abdomen  with  a ramrod at  the siege of Badajos, in
1812.   The instrument entered the front of the abdomen, and ac-
tually  stuck in the vertebrae, from which it could not  be disengaged
without force.*
   Patients, who have recovered from wounds of the bowels, should
afterwards be extremely temperate in their diet,  and, above all things,
avoid  taking  any kind of flatulent,  stimulating,  indigestible food.
 They must also be  very careful to keep their bowels regular.
   In  all  cases of  penetrating  wounds of the belly,  the  dressings
 should be light, simple, and  superficial.   If excrementitious matter
 be discharged from  the opening, the utmost  attention must be paid
 to cleanliness.  W"e should  also recollect the precept inculcated by
 Scarpa,  viz. that the external wound should  only  be allowed to
 close, in  proportion as the feces resume their natural  course, with
 ease and  regularity.
    Sometimes the intestinal matter continues to be  discharged  for
 a considerable  time from  the wound,  and  even during the  rest
 of the patient's life, either  through  a fistula,  or an  artificial anus.
 In general,  however, this  affliction gradually ceases.  In almost
 every collection of cases, we may find  examples fully proving,  not
 only that simple  stabs of the bowels in  the end get well, without
 leaving a permanent annoyance of this kind, but that  large portions
 of the bowels may  even be destroyed by gangrene, and yet the con-
 tinuity of the  intestinal  tube be completely re-established.  From
 the facts  quoted in  this chapter, it would also appear, that a com-
 plete division of a bowel  is neither certainly  fatal, nor necessarily
 followed  by an irremediable artificial anus.
   Balls,  shot into  the abdomen, are occasionally discharged with
 the stools.

                         EXTRAVASATION.

   An occasional  consequence  of a penetrating wound of the abdo-
 men is an extravasation in the cavity of the  peritonneum.   The  ex-
 travasated matter may be undigested food,  chyle, the succus pan-
 creaticus, feces,  bile, urine, blood, &c, according to the nature of
 the injured parts.   Fortunately, this kind of accident is far less  fre-
 quent than an inexperienced  surgeon would  apprehend, or than  our
* Obs. on Military Surgery, p 43f,  437. 
166
WOUNDS OF THE BELLY.
hearing so much of the cavity of the  abdomen would lead us to
expect.   Strictly speaking, no empty  space exists within the ani-
mal body; and all the parts, contained  in the abdomen, are in close
contact with one another, and  with the  inner surface of the  perito-
neum.  Hence, except under  particular circumstances, though the
bowels may  be  wounded, extravasation is generally prevented alto-
gether; or when it does  happen, the effused matter may all  lie in
one mass, and become circumscribed by the adhesive inflammation.
   If, immediately after a wound of the belly, and of its contents, it
be the compact  state of the contained and  containing  parts, which
at first hinders extravasation, it is that salutary process, the adhesive
inflammation, which afterwards renders the occurrence quite impos-
sible;  or bounds or circumscribes the effusion, if it should have al-
ready  taken  place.   In fact, all the surfaces in contact  with  each
other,  and surrounding the track of the wound, become generally so
intimately connected together,  by the adhesive inflammation, that the
wound forms a sort of canal, entirely destitute of all communication
with the cavity of the  peritoneum;  and the rapidity with which such
adhesions occur is very great.
   According to the investigations of Mr. Travers,  the following are
the only circumstances, in which  an effusion of the intestinal con-
tents can happen.   If the  gut be full, and the wound  extensive,
the surrounding  pressure is  overcome  by the natural action of the
bowel tending to the expulsion of its contents.  But, in defect of ei-
ther of these states, effusion  cannot follow.   When,  however, air
has escaped  from the bowel,  or  blood has been extravasated in
quantity within the  abdomen, at  the time  of the injury, the resist-
ance made to effusion will be less effectual, although the pressure
of the sides of the abdomen  is  the  same, as  such  fluids will yield
more readily than the  solids naturally  in contact  with each other.
Effusions more generally follow ruptures of the bowels by blows or
falls upon the belly, than ordinary penetrating wounds.*
  When an extravasation is perceived, in the first instance, a part
of the wound is  to  be  left open, and the posture of the patient is to
be so regulated, that the wound may be  as depending  as possible,
and the effused  fluid  readily escape.   If the extravasation should
not be perceived till after the wound has been dressed, we are di-
rected  to remove the means employed to close a  part of it, and to
place the patient in a proper posture, with a bandage applied round
his body.   When internal hemorrhage is suspected, and  the  state
of the pulse will admit of it,  venesection is proper.
  When symptoms of irritation exist,  attended  with local  inflam-
mation, pain, and a fluctuating tumor, denoting the seat of the  ex-
travasation,  the  effused fluid is to  be  let out by a puncture.f   In
* See an Inquiry into the Process of Nature in repairing Injuries of the Intestines,
c, p, 25—36.
t Richter'a Anfansgr. der Wundarzneykunst, band. v. p. 38. 
PSOAS ABSCESS.
167
the Memoirs of the Academy of Surgery may be found observations,
recorded by Petit  and Le  Vacher,  illustrating the advantages of
such treatment.
   When there are no symptoms denoting the exoct seat of the  ex-
travasation, the treatment should be restricted to the prevention,  or
diminution, of inflammation.  Venesection is to be resorted to, or
not, according to the state  of  the pulse; the belly fomented two or
three times a  day; and  only  liquid  aliment   allowed,  sometimes
merely  barley water.   In some cases, a bandage is  applied round
the body, as a means of  promoting  that compact  state of all  the
parts in the abdomen by  which  the  ill consequences of extravasa-
tions are so materially diminished.
   Musket balls may pierce and lodge in  the bladder,  in  which cir-
cumstances a surgical operation, resembling lithotomy, will become
necessary, as soon as the dangers of the  first injury are past.*   In
wounds of the bladder, a great  deal  of difference in  the degree of
danger  will  depend upon whether this organ happens to be full of
urine at the time of the accident, and whether the injured part of
it is one over which the  peritoneum is reflected.   In all  cases,
however, the principal danger depends upon the chance of the urine
becoming effused, and  exciting  inflammation  and gangrene of the
peritoneum,  bowels,  cellular tissue,  and, in  short, of  every part
with which it comes into contact.    The  obvious  indications are
to  make a free and depending  outlet  for^any  urine already effus-
ed;  to  prevent a further extravasation by  the  continual use of  an
elastic gum catheter;  to keep down  and  diminish inflammation  by
copious bleeding  and low diet; and to avoid every sort of dressing
at all likely to irritate or obstruct the wound itself.   The best appli-
cations, indeed, are light, simple pledgets, or lint kept soft with  te-
pid water,  the strictest  attention to cleanliness  being  paid.   The
cases are now numerous, in  which considerable wounds of the blad-
der terminated favorably under such treatment.!
         THE PSOAS,  OR  LUMBAR ABSCESS,

Is a collection of matter, formed in  the cellular tissue of the loins,
behind the peritoneum, and mostly descending in  the course of the
  * See Larrey's Mem. de Chir. Mil. t. iv., and Hennen's Mil. Surgery.
  t Such facts nre abundant in Larrey's excellent work, especially the 4th vol.  Fla-
jani relates another case, in which the means were restricted to antiphlogistic remedies.
Collcz. d'Osservazioni, t. iii. p. 3D.  Thomson saw fourteen examples of wounded
bladder recovering.  See Obs. in the Military Hospitals in Belgium, p. 108, &c. 
168
PSOAS  ABSCESS.
psoas muscle, until it produces a swelling below or above Poupart's
ligament, or glides under the fascia of the thigh.   In  a  few cases,
it descends into  the  pelvis,  whence it  passes  through  the sacro-
ischiatic foramen, and forms a sweHing near the the  anus.   Some-
times it passes backwards on the outer edge of the quadratus  lum-
borum, and  sacro-luinbalis muscles,  so as to  cause a  swelling
on one side of  the  loins;  and, in  some rare  cases, it takes the
course of  the  spermatic chord, and  forms a  tumor projecting
through the  abdominal ring,  such  as superficial observers  might
easily mistake for a hernia.   The disease furnishes one of  the best
illustrations of the nature of large chronic abscesses, and especially
of those usually regarded as scrofulous.  It begins with slight  un-
easiness in the loins, and a  weakness in walking;  but  no acute pain
may have been experienced, though the  matter be already copious
enough to produce an  external swelling.   By  degrees, however,
the quantity of matter becomes considerable, producing a  sense of
tension and weight about the loins, pains shooting down the lower
extremity, and  some degree of hectic disturbance of the  system.
As the disease advances, the lower  extremity of the  same  side be-
comes more and  more weakened, and the thigh inclines forwards.
In a girl, who was under my care in  University  College Hospital,
with a double lumbar abscess, both  thighs were drawn up close
to the abdomen.
   Lumbar abscess may or  may not  be combined  with caries of the
vertebra;; and the disease  of  the bone may be either the cause or
the accidental accompaniment of the collection of matter.   At the
same time I ought to mention, that my friend Sir Benjamin Brodie
is  led by his experience to believe, that lumbar abscess is rarely the
primary disease, but commonly originates from caries of the verte-
brae.   When a psoas abscess  is joined with disease of the lumbar
vertebrae, there is no paralysis, a peculiarity referred by Sir Benja-
min  Brodie to the greater magnitude of the bodies of the lumbar as
compared  with those of the  cervical or dorsal vertebrae, in conse-
quence of  which the former are not destroyed by the same degree
of caries which would be sufficient for the destruction of the latter.
In the lower part of the spine, the disease seldom reaches  the the-
ca vertebralis.   It  is the disposition of  lumbar  and other  chronic
abscesses to begin very slowly and insidiously, and  to increase in
the same way, until, from containing a  few ounces of matter, they
include at last several quarts.   The matter,  of  a lumbar abscess
frequently  presents flakes of a curdy  substance,  like those  seen in
other scrofulous abscesses;  and the  whole cavity, in which it col-
lects, is lined by a membrane  called the cyst of  the abscess, which
has  somewhat the  appearance of a mucous membrane, and is the
organ by w'hich, after the disease is established, the  matter contin-
ues to be incessantly undergoing secretion and  absorption.   The
extent of the surface of such a cyst may well be conceived, when 
PSOAS  AliSCESS.
169
it is recollected that a lumbar abscess sometimes contains a gallon
of matter.   Until the  quantity of matter  is enough to produce an
external swelling and fluctuation, we rarely have any positive know-
ledge of the existence of the disease,  which is often mistaken for
rheumatism.
   I have seen several  lumbar  abscesses, the swelling of which in
the bend of the groin more or less resembled  that of  a hernia, and
was attended with impulse  when the patient  coughed.   One case
was brought to my house:  there was a small soft prominent tumor,
with impulse, near the groin, but rather more towards  the ilium than
the place of a hernia, and accompanied by  a  larger swelling,—evi-
dently an abscess behind the os innomiatum.   I  recommended the
tumor behind to be opened, when, if it had a  communication with
that in the  thigh, the latter would subside, and indicate, at all events,
the nature  of the case.   Another  surgeon of great  experience ad-
vised the introduction of a needle into the  femoral tumor,  in order
to learn the quality of its contents.
   Attempts have been made to disperse lumbar abscesses by excit-
ing the action of  the  absorbents, by emetics, blistering  the surface
of the swelling, and the employment of purgatives.    The  plan has
been attended with little success.   Now as it is the nature  of lum-
bar and all chronic abscesses to become larger and larger, and
sometimes to attain vast magnitude before they burst,  it is, I think,
a good general rule to open  ihem as soon  as a fluctuation  can be
plainly distinguished.   It is found, however,  that the  plan of open-
ing a considerable lumbar  abscess is  frequently followed by a vio-
lent and even  fatal attack of irritative fever; and  hence,  some cau-
tion is requisite if the tumor be large.   In  fact, when we puncture
the abscess, discharge its contents, and leave the  opening unclosed,
the cyst often inflames over its whole  extent, and the patient now
suffers that violent derangement of the system, excited by any  fresh
irritation operating upon a hectical constitution, which  is well known
by the name of irritative fever.
   The knowledge of this fact  made  surgeons  fearful of following
this  practice, when  the  cyst  was of considerable   size.   Hence
arose the method of introducing a seton across the tumor,  and let-
ting the matter escape gradually ; and  Mr.  Abernethy's  more suc-
cessful way of letting out the matter by a  puncture, and then  clos-
ing it with adhesive plaster, and  healing  it  by the first intention.
The skin is to be  drawn to one side, the lancet introduced, and the
matter having  been discharged, the skin is allowed  to  resume  its
natural place again.   Thus ihe openings in  the skin  and the fascia
and cyst do not afterwards correspond, and the admission of air is
more likely to be  excluded.   The cyst remains for some time un-
distended—it has an opportunity of contracting—and, as soon as a
certain quantity of matter accumulates again, the  same proceedings
a re repeated.
   vol. n.                   15 
170         SCROFULOUS  CARIES OF  THE SPINE.

   With such treatment should be combined  the  administration of
tonic and  alterative  medicines, and  especially bark, preparations
of steel, the iodide of potassium, and such  as are found  to be the
best for scrofulous constitutions in a state of hectic.   After the ab-
scess has been considerably lessened,  blistering  the skin, or rub-
bing the skin freely with ung. iodidi comp.  will sometimes promote
the dispersion of the remains of it.   If the vertebrae be  diseased,
counter-irritation will be advisable; especially an  issue-or blister
kept open.   The fact established  by  Sir Benjamin Brodie,  that a
psoas abscess is almost constantly attended  with  caries of the ver-
tebras, must have a  very unfavorable influence  on the prognosis,
on account of the greater difficulty of curing any  abscess combined
with  disease of the  spine, than an abscess  free  from so serious a
complication.  The  double lumbar abscess in University College,
above referred to,  was  opened,  and terminated in  the  girl's re-
covery.
             SCROFULOUS  CARIES OF THE SPINE.

  Perhaps I may not be altogether justified in calling this affection
a caries of the vertebrae, because it  is alleged that  one variety of it
begins,  not with a  morbid alteration of the  cancellous structure of
any of those bones,  but with  ulceration of the  intervertebral sub-
stance.   But as the disease, in whatever texture it begins, generally
leads to caries of the spine, I think the name sufficiently appropri-
ate.   By adding the epithet scrofulous, we also distinguish this ca-
ries from other forms of it, as well as from necrosis, and  simple ab-
sorption of parts of the vertebral column, the effect of aneurism, or
other tumors,  not  usually productive of any  paralytic affection of
the lower extremities.
  In whatever manner the disease commences, if it be not checked
in its progress, it occasions a destruction of the bodies of the ver-
tebrae and intervertebral substance, leaving, as Sir Benjamin Brodie
correctly says, the posterior parts of the vertebrae  unaffected by it;
the necessary consequence  of which is an incurvation of the spine
forward,  and  a projection  of the spinous  processes posteriorly.
The same pathologist adverts also to the frequent and  early com-
plication of the disease with chronic inflammation of the membranes
of the spinal  cord,  and even of the latter organ itself,  which in
consequence of the curvature, and,  as I have  reason to believe,
still  oftener in  consequence of the  disease around the spine,  quite
independently  of the mechanical  effect of  the curvature itself, be-
comes disqualified for the performance  of its highly important func-
tion.   This observation is founded on  the fact of many cases being
upon record,  in which the most surprising degrees  of curvature, 
SCROFULOUS CARIES  OF THE  SPINE.
171
from destruction of the bodies of the vertebrae,  were  not  accom-
panied by  paralysis.   In the museum of University College is a
preparation, illustrating the earliest  change perceptible  in the most
common form  of  the  disease,—that  which begins  in. the  bones.
In the cancellous structure of the cervical vertebrae, small cells are
seen, which are produced by the removal of a portion of the natur-
al texture.
   Frequently in  caries of the spine,  and especially in scrofulous
cases beginning in the bones* suppuration occurs at a  very early
period of the disease, and, in other examples, not until  a late stage
of it.
   I have explained, in the first  section of this treatise,  the changes
in the shape of the spine produced by rickets;  where the curvature
is lateral, and the  spine twisted,  not from any carious  affection of
the vertebrae, but from their being only imperfectly developed, and
not calculated to resist the preponderating influence of  the muscles
and ihe  weight  of the parts, which the column has  to  sustain.
However  great such rickety curvature and  deformity  may be,  no
paralysis  is induced.   I  have also made some  remarks upon that
kind of absorption of the bones, which arises from the pressure of
aneurism and other tumors upon them, and which has  peculiarities
marking it very completely as a different affection from what is  de-
nominated caries;  for in no  situation, does it lead to the formation
of abscesses; and, in  the spine, it  is particularly remarked by  all
pathologists that it does not  give rise to paralysis.   Not, however',
that the thing is absolutely impossible; for,  in  the museum  of Uni-
versity College, is  a specimen of aortic  aneurism, which had occa-
sioned such an absorption of the lateral part of  the spine,  that the
medulla spinalis was exposed; though eveu  in  that case, 1 believe,
there  was no  paralytic  affection  of the lower limbs.   It is con-
ceivable,  however, that the mischief might have gone on, till palsy
bad been  excited by its effects upon the medulla spinalis; and I have
certainly read of a case or two,  in which the pressure  of an  aneu-
rismal tumor in the abdomen was the  cause of paralysis.   Such an
occurrence, however,  is at all events rare.
   The greater number of individuals, afflicted with scrofulous caries
of the spine, are infants or  children; yet many adults also  suffer
from  it, especially after  having been weakened  by fever, or a long
mercurial course.   It is very uncommon for it to begin after the age
of forty-five.
   It may be asked, how are we to distinguish scrofulous  cases,
commencing in the bodies of the vertebrae, from others, which  be-
gin in the  intervertebral substance ?  Now, the only information that
I  can deliver, in  reply to this question, is a remark  made  by  Sir
Benjamin Brodie, that where the  disease is  of a scrofulous origin,
affecting the  cancellous structure, he  suspects,  that it  is more im-
mediately followed by suppuration,  than  .vhere it  commences in 
172          SCROFULOUS CARIES  OF THE  SPINE.
the intervertebral cartilages; and thar, in the  latter cases, the  pain
and tenderness in the carious part of the spine are more consideiable
than in  scrofulous examples.
   With regard to the general symptoms of caries of the  spine, I
may remark, that, in the early stage, the patient has pain and  ten-
derness in that portion of the spine which is the seat of disease; and,
as I have stated,  perhaps these  symptoms will  be most strongly
manifested in  those  cases  in which the disease begins in  the inter-
vertebral substance.   If the patient be old enough to describe  his
complaints, he will tell us, that he is annoyed with a feeling of tight-
ness of the  chest, uneasy sensations  at  the pit of the stomach, a
torpid sluggish state  of the intestinal canal, perhaps some disturb-
ance in the functions of the urinary bladder, and weakness, aching,
numbness and cramps  in  the muscles  of the  lower extremities.
Now, it is scarcely necessary for me to say, that very  similar symp-
toms  may proceed from other causes ;  and even some of the infor-
mation respecting  the symptoms now enumerated, as appertaining
to the early  stage,  cannot  always be obtained, because  the patient
may be an infant.   Hence, until some inequality or projection be-
comes perceptible on the  spine  itself, and until the want of control
over the muscles of  the lower limbs and the paralysis are more es-
tablished,  the diagnosis is generally obscure.   The muscles and
parts  affected with paralysis must,  of course, be  those, which de-
rive their nerves from the portion of the medulla spinalis below the
seat of the disease.  Generally there is impairment of motion and
sensibility together; but sometimes one limb will  retain more or  less
sensibility, yet be deprived of the faculty of motion.
   In  different cases, the  symptoms differ considerably.  Some-
times there  is great pain in the part affected; sometimes none.   In
many instances,  the paralysis comes on early, and often even before
there is any material curvature  forwards; but, in some cases, we
see the  spinous  processes making a considerable angle  posteriorly,
in consequence of the bend of the spine forwards, and the destruc-
tion of the bodies of the diseased vertebrae, yet without  any paraly-
sis having taken  place.   The  true cause of most of the symptoms
is a morbid  state of the  spine  and parts connected with  it,  attended
with irritation  and disease, and perhaps  sometimes with  compres-
sion of the medulla spinalis itself.   The morbid state  of the spine
always precedes the deformity observable in  the vertebral column
itself.   Indeed,  the  curvature forward,  in such a degree as to pro-
duce the angular projection of the spinous processes  posteriorly,
cannot happen until the  bodies of the diseased vertebra?  have been
seriously injured by  caries.  The deformity is of a peculiar kind,
and such as nothing can produce, except the destruction of one or
more of the corpora  vertebrarum, the spine being bent forwards, as
I have already explained,  so as to form an angle backwards.  The
dy of one,  and sometimes the bodies of several  vertebrae mav be 
SCROFULOUS  CARIES  OF THE  SPINE.
173
eorrrpfetely  absorbed,  permitting  those  below and above the defi-
ciency to join, and be united by anchylosis.   The spinous process-
es may also be soldered together;  and the sides of the thorax press-
ed  downwards and  backwards, so  as to lessen, in  a very  serious
manner, the dimensions of the  hypochondriac region.   In this  dis-
ease, the  bones are large and  well  developed,  which  is very dif-
ferent from what is noticed  in  rickets.  In  curvatures from other
causes, there is not an angular  projection of  the spinous processes;
but the bend forms  the segmentof  a circle, generally affecting a
great extent of the spine, and often  assuming the  lateral inclination
or spiral  figure, with a  very conspicuous  leaning above, towards
the right side.
   In most cases of scrofulous spine, paralysis of the lower extrem-
ities, and even a more extensive  paralysis, will come on sooner or
later; but, in rickets, where the spine may be said to be deformed,
rather from an imperfect development of the bones,  than from dis-
ease of them, palsy of  the legs is not produced, however great the
lateral or spiral curvature of the back.  Professor Cruveilhier,  in
the 4th Livraison of his Anatomie Pathologique, gives us the par-
ticulars of a case, which proves how very far even  scrofulous  dis-
ease of the vertebrae will sometimes advance, without causing  par-
alysis, though this is a deviation  from what  is most  common.   In
Cruveilhier's case, no paraplegia existed, though not less  than five
of the bodies of the dorsal vertebrae  had been  totally annihilated;
and the alteration  in the shape of the vertebral column was such,
that the upper half formed with the  lower an extremely acute angle,
which would have been still more acute, if it had not been prevent-
ed by the eleventh and  fifth actually touching one  another.   The
intervertebral foramina  were all preserved, though more or less de-
formed,  contracted, or displaced  backwards.  In  those which
were most  diminished,  the  corresponding intercostal  nerves must
have been compressed, and consequently the action of the inter-
costal muscles impaired, explaining  partly the cause of the asthma-
tic disorder, with which the patient was troubled.  The engraving
in the above work shows how  nature contrived  to maintain  the  in-
tegrity of the vertebral canal,  and to keep the spinal cord from be-
ing compressed, in the midst of such a  surprising deviation of the
vertebral column from its natural configuration.   Although the bod-
ies  of five vertebrae were demolished, anchylosis took place, and
the medulla suffered no pressure  or  irritation adequate  to paralyse
the lower extremities.    A beautiful specimen, illustrative, 1 think,
of an equally extensive  destruction  of the bodies of the vertebrae,
and of as sudden a  bend of the  spine, will  attract  the attention of
every pathologist  who visits the museum of University College.
Cruveilhier also gives  the particulars of a child,  ten years  old,
brought lo the dissecting room, in which only a few vestiges of the
bodies  of the  third, fourth,  fifth,  sixth, seventh,  eighth, ninth,
                    15* 
174          SCROFULOUS  CARIES  OF  THE  SPINE.
tenth, and eleventh dorsal vertebrae were left.  According  to  this
pathologist, diseases of the vertebral column, like  those  of every
other part of the osseous system, are seated, not in the osseous tis-
sue itself,  but in the cellular or medullary tissue occupying its inter-
stices.   When this cellular tissue inflames, sometimes it pours out
pus in abundance, constituting an abscess, but sometimes in a more
scanty quantity so as  to admit  of absorption.  The  cells of the
osseous tissue, being distended  by the development of the cellular
tissue, and deprived of the materials of nutrition, may be entirely
absorbed;  and thus Cruveilhier accounts for the total disappearance
of the texture of bone, without a vestige of it being left.   In fact,
his doctrine is, that all disease is seated  in the cellular tissue of or-
gans, the other tissues being, according  to his views, only liable to
simple atrophy or hypertrophy.
   The view, now taken of this  subject, must render  it manifest,
that the removal of the deformity of the spine, even when we suc-
ceed  in  curing the  disease,  must be altogether   impracticable.
There must always remain an angular projection backward, which
will be greater or less, according to the  part of the spine affected,
and the extent of the destruction of the bodies of  the vertebrae.
   Nevertheless, we  are not to conclude, that every bend  of the
spine forward is from scrofulous disease.   We  have the authority
of Sir Benjamin Brodie for the observation, that a curvature of the
spine in this direction may arise  from other causes, as a weak con-
dition of the muscles, or a ricketty affection of the  bones.   Gen-
erally, he says, in such cases,  the curvature occupies  the whole
spine, which assumes the  form of a  segment of a  circle.   Occa-
sionally,  however, the bend  occupies only a  portion  of the spine,
usually that composed  of the superior  lumbar and inferior dorsal
vertebrae,  the curvature  being always  gradual, not  angular, a cir-
cumstance in which it particularly differs from the curvature result-
ing from caries.
   One common effect of scrofulous caries of the spine is the pro-
duction of an abscess around the diseased bone.  Yet, it frequent-
ly happens, that the caries will go on to a vast extent, and even  so
as to  demolish the bodies of several vertebrae, without any  abscess
being produced.   Disease  of  the spine  may continue  for years
without suppuration; but abscesses sometimes lie upon the diseased
bone, and are not detected till after death, when  the  body is ex-
amined.
   With respect to scrofulous  disease of the upper cervical verte-
brae, and of the articulations between the atlas  and  the condyles  of
the os occipitis, I may remind the reader of an observation.made
by Sir Benjamin Brodie, which is, that  the pain is greater in such
cases, than in others,  where the disease is  in the dorsal  or  lumbar
vertebrae.  When abscesses form from disease of the cervical ver-
tebrae, the matter  generally collects amongst  the  muscles  of the
neck, or  behind the pharynx, into which it may pass.  As the dis- 
SCROFULOUS
CARIES OF THE  SPINE.
175
ease advances, the arms become paralytic:  and this while the mus-
cles, which derive their influence from the spinal  cord below  the
neck, remain under the control of the will.   Afterwards, however,
the paralysis extends to the muscles of the trunk and lower extrem-
ities.   In  the case of a girl, eight  years old, with disease  of the
spino-occipital articulation, as recorded by Mr. T. R.  Blackley,
" the countenance  was  peculiarly expressive  of caution, and was        »
florid and full, if not bloated; the chin was advanced preternatural-
ly beyond  the chest; the mouth slightly opened; and she kept  the
arms parted from the side, as if to poise herself.   On  looking lat-
erally, she strained  her  eyes in the  direction of  the object,  and,
failing in this, turned her entire body for the purpose.   The  effect
produced, when she attempted to observe any thing placed near her
feet, was yet more remarkable;  for this purpose, she generally put
her hand to her forehead, as if fearful of undue weight  in the head,
and bent her body, thus avoiding the least motion  between the first
and second vertebrae.   In  getting up  from bed  also, or in lying
down, she invariably supported  the head with  the  hand."  During
the last four days of her life, the right arm was powerless."   The
post mortem appearances, which  are interesting, my limits compel
me to  omit.
   The most  approved  plan of treating scrofulous caries  of the
spine consists in employing, in the early stage, cupping or  leeches
over the part, followed by the application of blisters, caustic  issues,
a seton, or the moxa.   With the local abstraction of blood, are of
course to  be joined other mild antiphlogistic  remedies,  especially
aperient medicines, composed  of rhubarb, and the carbonate of
soda, castor oil, or the sulphate of magnesia.   After beginning with
these means, counter-irritation, or issues, setons, a perpetual blister,
or the  moxa, may be tried;  and these remedies  may be assisted with
the medici.ies  and regimen usually recommended for other scrofulous
diseases, particularly bark,  chalybeates, and iodine, with the benefit
of a light  nutritious diet, and  pure country air, if it can be conve-
niently had.   One thing is  quite  essential, namely, the  diseased
spine should be kept as quiet as possible, and  therefore the patient
ought to remain very much  in the recumbent position.  When  the
disease has existed a considerable time, and a conspicuous angular
curvature is formed, I think Sir B. Brodie's advice should be  fol-
lowed, which  is, to let the patient recline on his side, instead  of on
his back;  or if this posture be disagreeable, he should not lie  on an
absolutely  flat surface, but  be supported  with pillows, so that  his
position may have no tendency to  restore the spine to its original
figure,  which would only have the pernicious effect of disturbing the
completion  of the  anchylosis, by  which  alone the cure  can be
accomplished.
* See Dublin Journ. of Med. Science, vol. xii. p. 62. 
176
SPINA  BIFIDA.
  Of late years, issues and  blisters, from having been employed in
these cases for immoderate periods of time, and without discrimina-
tion, have become objects of abuse by certain  practitioners.  Yet,
that  they frequently  produce great benefit, I am convinced  by re-
peated experience.   We often find paralysis suddenly cease, or di-
minish, on the application of a blister.  At the same time,  I am of
opinion with  Sir B. Brodie, that issues  are chiefly useful in  the
early stage of the disease, with the view of preventing suppuration,
and that they are of  no service  after an abscess has actually formed.
He likewise suspects, that  issues are of little  or  no service where
scrofulous disease of the cancellous texture precedes ulceration of
the cartilages.  If this  be  true, we  see, then, the reason why so
many cases are not  benefited by this plan; but it is a point for fur-
ther investigation, and  one on which  I cannot  say, that my expe-
rience agrees with what lias now been suggested.
  I may next observe, that the medulla and its coverings are liable
to chronic inflammation and its effects, as a consequence of exter-
nal violence.  Cases are likewise sometimes met with, where scrof-
ulous tubercles form in the  medulla itself.  Any of these changes
may of course impair  the  functions  of this important  organ, and
bring on paralytic affections.   The treatment must be regulated by
principles applicable to diseases of joints, and  comprise very much
the same means which have been advised for  scrofulous disease of
the bodies of  the vertebrae;  local bleeding, counter-irritation, quiet-
ude in the  recumbent position, and  medicines and regimen for the
improvement of the health in general.

  SPINA BIFIDA,  HYDRO-RACHITIS, OR THE CLOVEN SPINE,

Is a congenital malformation, consisting  in  a  deficiency of one or
more of the spinous processes and arches of  the vertebrae, which,
indeed, are sometimes  deficient throughout the whole extent of the
vertebral column.   In consequence of the deficiency of the back
part of the spinal canal, the theca vertebralis protrudes, and forms
a kind of pouch filled  with a limpid fluid.  The  swelling is of  dif-
ferent sizes in different cases, according to the  extent of the malfor-
mation in the bones, and  the age of the individual.  The most com-
mon situation of it  is on  the lumbar  vertebrae; but  it may  take
place on  the dorsal  or cervical ones, and even  the sacrum.   In
some cases, an aperture  is left in the bodies of the vertebrae, in ad-
dition to the absence of  the spinous processes.  All the processes
are occasionally deficient, and  the vertebrae small, and not properly
developed.   The swelling  is  soft, and  attended with  fluctuation,
and sometimes. a  degree of  transparency.  It generally subsides
when compressed, but returns as soon  as the  pressure is removed.
The skin retains its  natural  color, and there is no pain  in the partr
anless it be compressed. 
SPINA  BIFIDA.
177
  Children born with  spina  bifida seldom  live more  than a year.
They are generally weakly and emaciated; and  very often afflicted
with paralysis of the lower limbs,  and of the sphincters of the blad-
der and rectum.   However,  I have seen children with spina bifida,
who had a healthy appearance and suffered no paralytic complaints.
Sometimes, also, instead of  dying in infancy, they live to the adult
age, as was the case with a young woman, whom I saw many years
ago under the care of  Mr. Copland Hutchinson.  The  urine  and
feces passed involuntarily.   The tumor was of such enormous size,
that it measured in ihe vertical diameter thirty inches.
  With very few  exceptions, spina bifida proves fatal; and this, m
the greater number of instances, within the first year from the period
of birth.   Some children thrive for a few years, and appear to suf-
fer little or no  inconvenience; but no sooner does the tumor burst,
or is it punctured, than convulsions usually come on, and  the little
patient suddenly dies.   This was the final result of a case, in which
I saw a little boy, about two years  old, that was in  perfect  good
health, and with the free use of his legs, though he had a spina bifida
on the sacrum nearly as large as his  head.
   Gentle pressure on the tumor was suggested as worthy of trial by
the late Mr. Abernethy, with the  view  of producing  an absorption
of  the  fluid; and, if that  object could not  be accomplished,  he
deemed the experiment of letting  out the  fluid by a small puncture,
and then closing the opening with sticking plaster,' quite warranted
by the commonly fatal course of the  disease.   This was done in
one example, the  puncture being repeated every fourth  day for six
weeks, and regularly healed; but, at length, one of the  punctures
failed to unite,  the sac inflamed, pus was formed, and the result  was
fatal.
   Sir Astley Cooper tried the effect of puncturing spinas bifidae with
a fine needle.   In one case,  the fluid was discharged, and  the cavi-
ty  obliterated  by the adhesive inflammation, so as to  produce  a
radical cure.   This gentleman, however, besides the radical treat-
ment, if it can be so called, as it is only supported by  one or  two
instances  of success,  has a palliative method, which  consists in
treating the protrusion  on the principle of a hernia, and  applying a
compress and bandage to it.*
   Spina bifida, when  joined with hydrocephalus, paralysis of the
lower extremities, and  involuntary discharge of the urine and feces,
is entirely a hopeless case.  The same observation  applies to ex-
amples in which the spinal cord itself is deficient.
   In many children,  the bodies  of the vertebrae are not  perfectly
developed, the ossification of the cranium is not complete, and the
  * Two patients treated in their infancy on these plans, and now grown up to be
■trong men, I have lately examined by the favor  of Sir Astley Cooper, under whosa
care they were about twenty years ago, or more. 
178
HERNIA.
disease is associated with other deformities, such as club feet.   All
these circumstances were illustrated in a case, from which a prepara-
tion in the museum of University College was taken.    The  child
lived  only three days.
   [Hydro-rachitis or spina  bifida, is  a disease of  the brain  and its
membranes, which is followed by an effusion  of serum ;  and  the bi-
furcated condition of the  arches of the vertebrae, is caused by the out-
ward  pressure of the  membranes of the  medulla spinalis, in conse-
quence of their containing water.  The tumor is most often  situated
in the lumbar region, still it does occur at all  points of  the vertebral
canal.  Sometimes  there  is  but  one of the  arches wanting, and at
other times they are all  wanting, from the  head to the coccyx.  When
there  is but one arch wanting, the tumor  is pendulous, and the cover-
ings consist of  the common integuments  of the body, and the menin-
ges of the medulla ; but when there is a deficiency of several of the
arches, the base of the sac  is large, and  its walls,  especially the pos-
terior  portion, are diaphonous, and their structure fibrous instead of
tegumentary.
   The prognosis in these cases is unfavorable, the patients usually die
soon after birth.  Dr. John T.  Lewis, of Eatontown, N- Y., has re-
ported to me the case of  a man, who,  with one of these tumors, mea-
suring thirteen inches in circumference at the base, and twenty inches
in its  largest transverse diameter, lived to the  age of thirty years.
   In addition to the treatment mentioned  by Mr. Cooper, I have seen
two cases cured by ligation, as suggested  by Mr. Benjamin  Bell.  In
both of these,  the sac was covered  by the common integuments and
the base of the  tumor was small.   The  last  of these two cases was
treated at the Clinique  of  the College  of Physicians and Surgeons, in
New York, June 5th, 1844, by Dr. L.  A. Sayre, Prosector of Surgery.
The patient was two years old, and enjoyed good health.    The tumor
was situated at the lower  part of the cervical region.  A  needle arm-
ed with a double ligature,  was carried  through the base of the tumor,
and then firmly tied ;  after which it was excised outside the ligature,
and is now in rny museum at the college.   The ligature  came  away
on the twenty-third day, the wound  being then entirely  healed; and
the patient completely recovered.—En.]
                          HERNIA.

  The term hernia is applied to a  protrusion of parts from any of
the  greater cavities of the  body: thus there may  be herniae of the
brain, lungs, or abdominal  viscera.   The  expression rupture, em-
ployed synonymously with hernia, signifies, however, only the ab-
dominal form of the disease, and came into use  from an erroneous
notion, that the parts,, through which the protrusion happened, were 
HERNIA.
179
constantly burst or torn.   When any of the viscera of the abdomen
protrude, they almost always push out, along with them, a  portion
of the  peritoneum, which forms a kind of pouch in which they are
contained, and is called the hernial sac.  Of this the narrow  part
is termed the neck, and the more expanded part the body.
  But  hernia is attended  with infinite variety, so that it will  not al-
ways admit of being  defined  to be a protrusion  of the viscera, in-
cluded in a peritoneal sac; for  the  parts may  not protrude at all;
the displaced or entangled bowels may form  no external swelling;
they may be entangled in some unusual aperture in the  mesentery,
or be compressed  by adhesions formed within the abdomen; or,  if
they do protrude,  they may not be  entirely covered by a peritoneal
sac.   The total or partial  absence of a sac, however, is the pecu-
liarity  of but  few cases,  as when a hernia follows the cicatrisation
of a penetrating wound of the  abdomen, or when the sac   is  ren-
dered imperfect by ulceration or absorption, or is torn by accidental
violence directly applied  to the tumor.    The bladder and   coecum
are not contained  in  the  peritoneum, and hence,  when  they  form
herniae, they have  not a complete hernial sac; they do not push out
the peritoneum before them,  but draw after them the  portion of that
membrane with which they are naturally connected.   Thus a  kind
of sac may follow them,  without covering them, and into such sac
other bowels may fall.
   The most common  situations for herniae are the abdominal  ring,
the navel, and a limited point below Poupart's ligament, just at the
inner side  of  the  femoral vein.   They are also  met with  at every
point of the linea  alba, and, in  less  common instances, at the  fora-
men ovale, at the  ischiatic notch, in the perinaeum,  or the  vagina.
Hernial protrusions are also possible through the diaphragm into the
chest,  sometimes through a lacerated opening in that  muscle, some-
times through a natural aperture in it, or one from congenital malfor-
mation. The contents of a hernia are mostly either intestine or omen-
tum, or both together.  The small  intestine, being more moveable
than the large, is more frequently protruded,  especially that portion
of it named the ileum, which lies very near the ring  and the space
below  Poupart's ligament.  Sometimes the protrusion will comprise
merely a part of the diameter of  the intestine;  and sometimes sev-
eral inches  or feet  of it may be contained in the  sac.   In  rarer
forms of hernia, other parts are met with, as portions of the stomach,
or liver, the spleen,  uterus,  ovaries, or bladder.
   From the two circumstances of situation and  contents, are deriv-
ed nearly all the various names of herniae.   Thus, when the tumor
contains intestine alone, it is called enterocele; when omentum alone,
cpiplocele; and,  when  its contents consist  of  both  parts, entero-
epiplocele.   We hear also of hernia of the stomach, bladder,  &c.
With respect to names derived  from situation, when  the  protrusion
is at the abdominal ring, or even  merely within  the inguinal canal, 
180
HERNIA.
the case is termed a  bubonocele or an inguinal  hernia;  but if the
parts come out of the same aperture, and  descend further, so as to
get into the scrotum,  such form of the disease is termed oscheocele,
or  a scrotal hernia.   The  protrusion  below Poupart's  ligament,
just on the inner side of the femoral vein,  receives the name of cru-
ral or femoral hernia.   A protrusion at the naval is termed an ex-
omphalos, or an umbilical hernia; and,  at any  other  point of the
front of the abdomen not yet specified,  a ventral hernia.  Protru-
sions by the side of the vagina, at the foramen ovale, in  the  perin-
aeum, through the diaphragm,  or the ischiatic notch, are named ac-
cordingly, hernie of  the vigina, foramen ovale, &c.   One kind of
hernia, named from the circumstance of children being born with it,
or  having  it very soon after  birth,  is  called congenital, which ;s
likewise  singular in another respect, viz.,  that of having the tunica
vaginalis for the hernial sac.
  When the protruded viscera create  no  disturbance, and readily
admit of being put back into  the abdomen, the hernia is said to be
reducible; but when they cannot be put back, owing to adhesions,
or their large size in relation to the  opening, through which they
would have to return, the hernia is called irreducible, or incarcerat-
ed.    If the parts be not only  difficult of reduction, but subjected
to such pressure, or constriction, as impedes  or deranges their func-
tions, stopping the passage of the intestinal matter towards the anus,
causing frequent sickness, with inflammation or worse consequences
in the constricted parts, the case is well known  among surgeons as
a strangulated hernia
  The causes of hernia are divisible into the predisposing and excit-
ing.  With respect to the first, 1 may remark, that a natural defi-
ciency of resistance in any part of the  boundaries of the abdomen,
and a loose, very moveable state of certain  viscera, must  be re-
garded as the common  predisposing causes.   According to the ob-
servations of Sir Astley Cooper, debility predisposes to  hernia by
occasioning a relaxation of fibre, and a dilatation of the aperture
through which the spermatic vessels  pass.   If a  person, debilitated
by fever, return to habits of violent exertion before his  strength  is
fully re-established,  a hernial  swelling will  frequently take  place.
It is on the  principle of general relaxation,  that the same distin-
guished surgeon explains the remarkable frequency  of the disease
in old persons, especially those who work  hard.   Hot climates, by
producing relaxation, and all circumstances, which tend to bring on
a sudden absorption of fat, are well known to give a tendency  to
the  formation of hernial swellings.   Many facts  also support the
doctrine, that herniae are sometimes particularly prevalent in certain
families,"so as to be called hereditary, and no doubt  this depends
upon a weaker conformation of the parts where  the tumors  form,
than is exemplified in the generality of individuals.
  The exciting causes may all  be referred  to the powerful action of 
REDUCIBLE HERNIA.
181
 the  abdominal muscles and  diaphragm  on the viscera; and  this is
 the  reason  of the great  frequency of the disease in the laboring
 classes, in dancers, in the inhabitants of mountainous countries, in
 the cavalry, in persons who ride hard, &c;  persons who lift heavy
 weights, who suffer from asthma, or from long-continued  cough,  or
 who habitually exert their lungs in any kind of manner, are principally
 subject to hernia.  Costiveness likewise creates a risk of hernia, which
 usually comes on when the person is straining at  stool.   Strictures
 of the urethra also promote the formation of hernia, the abdominal
 muscles being required to act with unusual force in order to  empty
 the bladder.   Cases  are recorded, in  which  several hernial tumors
 were  thus occasioned  in the same  individual.   The  same causes,
 which first produced the complaint, are constantly tending to  pro-
 mote its increase.  The tumor becomes larger, in proportion as the
 pressure  against  the  hernial sac  is stronger and more frequent.
 Hence the great size  which it often attains in  persons  following la-
 borious occupations.   Its increase will also be in proportion to the
 less  considerable resistance of the parts in which  it is situated;
 hence the magnitude of scrotal  ruptures, and the  generally small
 size  of a femoral  hernia.  Sir Astley  Cooper adverts to one con-
 dition conducive to hernia, through an altered state of the viscera,
 the abdominal muscles being nearly passive;  this is when the viscera
 become, as it were, too large for the belly, from  extreme obesity,
 the fat accumulating in extraordinary quantities in the omentum and
 mesentery.   The enlargement of the uterus in pregnancy, as every
 surgeon  knows,  gives a  great   tendency  to the  occurrence  of
 umbilical and  ventral herniae, by  over-distension of the abdominal
 parietes.
   At the first  moment of the occurrence of a suddenly formed her-
 nia,  the protruded peritoneum must be unconnected with the parts
 amongst which it lies;  but, in a very short time, it becomes  firmly
 bound to them by the adhesive inflammation, which then prevents
 the return of the sac into the  abdomen on  the viscera being reduc-
 ed.
   The great apparent increase in the thickness of the sac is  most-
 ly owing,  not to such  change in the peritoneal sac itself, but to that
 of the more external coverings of the tumor,  as the  fasciae, cremas-
 ter, and cellular tissue.   However, there are exceptions,  in which
 the hernial sac is really much thicker than the rest of the  peritone-
 um;  especially when  the  tumor, after having been  long  reduced,
protrudes agiin,  and is not kept up;  when  it  has been repeatedly
affected with  inflammation; or there a>e extensive adhesions  be-
tween the" sab  and its contents.

                     REDUCIBLE HERNIA.

  The general symptoms of a reducible hernia are an  indolent  tu-
  vol. n.                  16 
182
HERNIA.
 mr r, situated at  one of the  points of the abdomen, already speci-
 fied as the places for hernia; sometimes originating gradually, some-
 times suddenly, and subject  to change of size, being smaller when
 the patient lies down on his back, and  larger when  he stands up or
 holds his  breath.  Frequently jt diminishes when compressed, and
 grows large again when the pressure is removed.   Its size and ten-
 sion often increase  after  a meal, or when  the patient is flatulent.
 In many cases, colic, constipation, and vomiting occasionally take
 place, seemingly from the bowels being out of their natural situa-
 tion, and  less capable of  their usual  action on  their contents; but,
 in others, the functions of the bowels  go  on quietly and regularly.
   When  the sac contains only a  piece of intestine,  forming  what is
 termed  an enterocele, the tumor  is  characterised by elasticity and
 uniform smoothness.   No pain attends the  handling of it;  and, on
the patient's coughing,  while the surgeon's hand is applied  to the
 part, a forcible impulse is felt, as if air were  blown  into the swel-
ling.   The bowel generally returns into the abdomen with great fa-
 cility, a guggling noise being frequently heard at the moment.
   If the sac contain only omentum, constituting epiplocele,  the tu-
 mor has a more flabby and unequal feel;  is more inclined to be ob-
long than  round;  and if the quantity of protruded omentum be con-
 siderable, the disease is  in some degree indicated  by its weight,
which is  greater than that of an enterocele.   Here, also,  an im-
pulse is felt in the tumor when the patient coughs.   In very young
subjects,  the contents of a hernia are  generally intestine, and sel-
dom omentum.
  With respect to the signs of an entero-epiplocele, or hernial tu-
mor, containing both  omentum and  intestine,  if a part of the con-
tents slip  up suddenly and with  a  guggling noise,  leaving  behind
something which  is less easily reduced, the disease is an entero-ep-
iplocele.
   The general treatment  of a reducible hernia is perfectly obvious.
 The protruded  viscera are to be returned  into ihe  cavity of the
belly, and a truss applied  for the purpose of preventing their de-
scent again.   The manual proceedings, by which the contents of a
hernia are reduced, without  the  use of the  knife, are termed the
taxis, the manner of performing which varies according to the situa-
tion of the tumor.
   If no means be employed for  reducing  the parts, and keeping
them reduced, there will be a constant risk of the hernia  becoming
strangulated  by an  additional protrusion  of more bowel or omen-
tum into  the sac.  But,  besides this  danger, and  the loss of all
chances of a  radical cure, when a  reducible hernia is neglected,
other considerations  should be pressed upon  the patient, to make
him understand the necessity of  regularly keeping up the parts with
a truss.    It should  be represented  to him,  that, if  he neglect thi;
precaution, the hernia will increase in size, so as not only to prr 
IRREDUCIBLE  HERNIA;
183
 vent all active exertion, but,  if a bubonocele, to  impair the genital
 function by involving the integuments of the penis, and  sometimes
 also, by the pressure, causing a wasting of  the testicle.   In partic-
 ular, as the early period of life is that iti which the opening has the
 greatest disposition to close,  infants and  children should  never  be
 suffered to be without a proper truss;  and it is now perfectly ascer-
 tained, that they can wear trusses with steel springs just  as well as
 adult subjects.
    Though such are the doctrines which  I  have  to offer  in relation
 to the general treatment of reducible  hernia, cases sometimes pre-
 sent themselves  in which the contents of  the hernia are so  bulky
 that, though reducible,  they cause, after their return into  the  belly,
 so much pain and  indisposition,  that  it  becomes  necessary  to  let
 them continue in the sac, which should  then  be supported with a
 suspensory bandage.

 IRREDUCIBLE HERNI.E FREE FRO"M  INFLAMMATION, AND TROU-
              BLESOME  OR  DANGEROUS SYMPTOMS.

    The usual  causes, preventive of reduction in such  cases, are,
 first, the  bulk of the  protruded parts, in  relation to the  opening
• through which they would have to return;  secondly, alterations in
 their form and texture; thirdly, adhesions to one another, or  to  the
 inside of  the  sac;  fourthly,  transverse membranous  bands  within
 the sac, or the neck of it; fifthly, some herniae are rendered irredu-
 cible, because the  viscera are bound down  by their natural cellular
 connections, though in a state  of displacement.  The  bladder is
 generally  incapable of  being  completely returned; and  the hernial
 sac, where the coecum  protrudes, is deficient behind1' and  at the out-
 er side of the  tumor, where  the  bowel  has only its  usual cellular
 attachment.
    The course of the intestinal  matter is,always more or  less  ob-
 structed in that portion of the bowels which is included  in  the her-
 nia; and hence,  patients  with irreducible enterocele are  frequently
 subject to complaints of  the  digestive organs, colic  pains, or even
 a  total stoppage of evacuations  per  anum; not the result of any
 constriction of the  protruded bowel, but of the difficulty with  which
 its contents pass through  it.
    Persons with  irreducible ruptures should avoid rough exercise,
 support the tumor with a  bandage, and keep it out of the way of all
 harm  from pressure or bruises.   They should also  be careful to
 avoid costiveness, and  irregularity of  diet.
    An irreducible omental hernia,  free from constriction and inflam-
 mation, may not be the cause of much present inconvenience; but,
 when affected with inflammation from any accidental cause,  or when
 a  portion  of  bowel slips into the sac with it, severe and fatal conse-
 quences may ensue. 
184
HERNIA.
      GENERAL  SYMPTOMS OF  A STRANGULATED  HERNIA.

   The first symptoms are  a tumor in the  situation of the hernial
protrusion,  attended with pain,  not  only in the part, but  about the
diaphragm,  followed by eructation,  sickness,  inclination to vomit,
suppression of stools, and acceleration of the pulse.   The suppres-
sion of stools is often as complete and as irremoveable by purgative
medicines, when  only a small portion of the diameter of the bowel
is  strangulated, as when an entire fold of it is pinched.  The action
of a clyster on the bowels below the stricture often produces a stool
after strangulation has taken place; but when they have once been
emptied, the most irritating clysters have no effect.   If the reduc-
tion be delayed, the bowels are distended with air;  the belly is tense
and swollen from this cause; the vomiting and  eructations become
more  frequent,—all the contents of the stomach, and afterwards
those of  the bowels  down to the stricture,  being rejected.   After-
wards, the  pulse, which was previously about 90,  and,  perhaps,
strong and hard, becomes much  quicker and weaker, and  the belly
is  very sore on pressure.   Peritonitis has now  come on,   There is
great  anxiety  and  restlessness,  with a small,   quick,  hard  pulse,
and generally  cold  extremities.  After  a  time,  hiccough occurs,*
the pulse sinks,  and the whole  body becomes covered with a cold
clammy  perspiration.   Mortification next  takes  place,  beginning
in   the the  protruded viscera and extending to the  containing and
neighboring parts.  The patient may now experience a sudden feel-
ing of relief, but this is only temporary.   The tumor becomes em-
physematous, a sure sign of the  gangrenous mischief within it.  In
this state, the  gut either goes up spontaneously or is returned with
the smallest degree  of  pressure; but, the hiccough and cold  sweats
continuing, the pulse becomes more and more rapid and   irregular,
and death soon follows.
   When the body is examined, the  whole surface of the peritoneum
is  found  inflamed, the intestines  participating in the disorder,  partic-
ularly those above  the stricture, which are considerably  distended
with air.  From the strangulated part downwards, the intestine is
generally smaller than usual,  and  sometimes not  inflamed.   The
convolutions are also frequently connected  together  by recently
 formed adhesions;  a turbid puriform fluid is effused in the abdomen;
and,  not unfrequently, spots  of gangrene  are  seen on  the  intes-
tines.
   The  symptoms of a strangulated epiplocele are less severe and
rapid, and stools may generally be procured by purgatives and clys-
ters;  but this is   sometimes attended with  great difficulty, and the
sickness and vomiting are, for  the most part truly distressing.  In
the museum of University  College is a preparation, exhibiting the
production  of a permanent stricture of  the inner  coat  of a por- 
STRANGULATED" HERNIA.
185
 fion of bowel that had  suffered strangulation: an exceedingly rare
 occurrence.
   General Treatment of a Strangulated Hernia.—Surgeons should
 always remember the necessity of not losing too much time in the trial
 of means not to  be  depended upon for  procuring the reduction of
 the parts for the rapidity with which gangrenous mischief sometimes
 takes place  in the hernia, attended by a dangerous and fatal degree
 of  inflammation  within  the  abdomen,  is  very  remarkable.   The
 greater number of patients, who die after operations for strangulated
 herniae, do not die of those operations abstractedly considered, but
 rather  of the effects of the disease; and  if the knife  were  used
 more promptly, life  would more frequently be saved.   I fully coin-
 cide in the opinion  entertained by  many  surgeons, that we should
 save  many  more lives  by operating on strangulated  hernia much
 sooner than is generally done.   1 would recommend  a  fair  and
 prompt trial of those means which are the most likely to  promote
 the reduction of  the hernia;  and  if they failed, and the symptoms
 were urgent, it seems to me  that  time ought not to be wasted in the
 useless repetition of them, or the employment of others known  to
 be less efficient.
   The taxis, or an attempt to reduce the parts with the hand, is, of
 course, the  first proceeding for adoption.   For this purpose the ab-
 dominal muscles  and femoral fascia should be relaxed by  inclining
 the chest forwards, and bending the thigh and rotating  it   inwards.
 In  the external inguinal hernia,  the pressure should be  directed
 upwards and outwards, along the course of the  spermatic cord;
 but, as the femoral hernia passes  first downwards and  then forwards
 and upwards, the pressure in this case  must be directed first down-
 wards and then backwards,   in  umbilical and ventral hernia;, it is
 to be made  directly  backwards.   No violence ought to be used,  as
 it can be of no service,  and must increase  the inflammation of the
 bowels.  The intestine may even be burst by too much force, or the
 sac forced into the abdomen, with  the  viscera strangulated by its
 neck.   While the tumor is grasped with  one hand, and moderate
 pressure on  it steadily kept up, the  fingers  of the other hand are to
 be employed in the e.ideavor to get up any portion of the contents
 of the hernial sac, and  to keep it reduced, until followed  by another
 portion.   If air be felt  to return, this  will be encouraging.   Dr.
 OVBeirne's  plan  of  lessening the contents of the abdomen,  and
 thereby some of the resistance to the reduction, by discharging the
 air from the  the large intestines with an elastic gum  tube, appears to
 me to  deserve greater attention than it has yet received  from the
 profession.   If the first  trial of the  taxis should fail,  we  may put
 the patient into a warm bath,  if it can be prepared without too much
loss of time; and while he is in it, take blood from his  arm.  If the
warm bath should require much time for its  preparation, I would ad-~
vi6e it to be dispensed with, and  blood taken from  the arm.
                            16* 
186
HERNIA.
  The object of the warm bath and bleeding is to render the pa-
tient weak and faint, to bring on a kind of  general  collapse, during
which the taxis may often be practised with success.   If the patient
should fall into this  state,  therefore, the opportunity of trying the
taxis again is to be taken.
  Supposing, however, we were not yet able to succeed, what ought
to be done?  If the patient  were not  a  very  old  or debilitated
subject, I  should next try  the united effect of cold or ice applica-
tions to the swelling, and of an  infusion  of tobacco thrown up the
rectum:  5}.  of tobacco is  to be infused  for ten minutes in a pint of
boiling water poured upon it;  the liquor  is  then to be strained, and
one-half of it injected first; and if in  about a quarter of  an hour,
this produce not too violent effects,  the other half is to be thrown
up.   When  the patient is under the influence of the tobacco, and
the  tumor  has  been   subjected  to  the  cold  applications some
little time,  the hernia will  sometimes return  of  itself, or  with the
slightest assistance.  If it should  not,  the taxis is to be  tried for
the last time; and, if it now fail, and  the symptoms be urgent, and
peritonitis present, the operation ought to be performed without fur-
ther delay.   Although I would not generally employ  the  tobacco
enema in  old weak  subjects,  one  exception  deserves notice; and
this is, when such an individual  absolutely  refuses to  submit to an
operation.   One, or two cases* of this kind have been attended by
me in University College Hospital, and the practice was so success-
ful, that, as soon as the patients came under the influence  of the
tobacco, the contents of the hernial sac  returned into the abdomen,
almost without the aid of  any manual proceedings.
   I have  little  faith in purgatives and opium, except in cases of
strangulated  epiplocele, or where  there  is  reason to  believe  that a
part of the  contents of the  tumor has been reduced.   We are
sometimes called to cases in which so much time has been  lost, that
we only just have an opportunity of trying  the effect of tobacco and
cold, or even not of them.

      ANATOMY OF INGUINAL HERNIA,  OR BUBONOCELE.

   It will be  impossible to understand the subject of inguinal hernia,
unless we are acquainted  with the anatomy of the passage through
which the spermatic cord naturally proceeds, in  order to reach the
scrotum, and through   which  the  most  common form of inguinal
hernia takes  place.   We must also understand the coverings of the
spermatic cord,  because they  are also the  coverings of inguinal her-
nia; and, in  addition to these  matters, we should  have a clear idea
of the situation of this hernia, in relation both to the spermatic ves-
sels and the  epigastric artery.
   The abdominal ring, or triangular opening in the  tendon of the
external oblique muscle, the base of which corresponds to  the crista 
ANATOMY OF INGUINAL  HERNIA.
187
 of the os pubis, is the  external termination or  outlet of the canal
 through which  the spermatic cord passes.  The upper, inner, and
 weaker  pillar of this opening is inserted  into the symphysis of the
 os pubis, and its lower, outer, and stronger pillar into the angle and
 crista of that  bone.  In  the  living subject, it  is not an unclosed
 aperture;  for, besides being occupied by the cord,  it has the inter-
 culumnar fascia extended over it.  The inner opening or commence-
 ment  of the passage, designed for the  spermatic  cord,—the very
 place, in fact, where the viscera first protrude in the most common
 kind of inguinal hernia,—is not situated  directly behind the abdom-
 inal ring, but about an inch and  a  half  from it, in the direction to-
 wards the anterior  superior spinous process of the ilium.  Or, I
 may say, that the inguinal canal, as it is generally  named, is about
 an inch and  a half in length; the internal ring  being situated very
 nearly midway between the symphysis of the pubes and the ante-
 rior superior spinous process of the  ilium.
    From this description, it is manifest, that the direction  of  the in-
 guinal canal must be oblique, extending  downwards, inwards, and
 forwards.
    But the student will naturally ask, what  parts form the inguinal
 canal?  In order to understand this  part of the subject, it should be
 remembered, that a thin fascia, termed the fascia transversalis, first
 accurately described by Sir  Astley Cooper, is extended from  the'in-
 ner margin of Poupart's ligament, over the posterior surface of the
 transverse  muscle,  thus forming a kind  of partition  between the
 abdominal ring and  the peritoneum, and also forming, with a portion
 of the united fibres of  the transverse and internal  oblique muscles
 near the crista of the os pubis, the  posterior boundary of  the  in-
 guinal canal, the anterior side of which is formed, to the extent  of
 its first third from the inner ring, by the transversalis and internal ob-
 lique muscles,  and,  in the  remainder of its continuation, by the apo-
 neurosis of the external oblique.
   The precise point, at which the most common forms of inguinal
 hernia begin, corresponds, in the adult, to the passage of the sper-
 matic cord under the edge of the transverse muscle.  In the sound
 state,  this part of the peritoneum  has a small funnel-shaped depres-
 sion in it;  and it is this small digital kind of pouch, whose progres-
 sive enlargement constitutes  the hernial sac, the hernia in its course
 always following the direction of the spermatic cord, in front of the
 vessels of which it is situated.
   In point of fact, the opening which constitutes the internal ring
 or commencement of the inguinal canal, is  the aperture in the fas-
 cia  transversalis,  designed for the  passage of the spermatic cord
 into that canal.   Now  the cord, in  passing through this  opening,
 carries along with it a covering derived  from the margin of such
 aperture in  the fascia transversalis, which covering is termed  the
funnel-shaped process of the  fascia transversalis.   It is the least im- 
188
HERNIA.
 portant of the investments of the hernia;  for, after it has descended
 a little way,  it is lost in the cellular tissue,  between the peritone-
 al hernial sac and the cremaster.
   The spermatic cord, invested by ihe funnel-shaped process, then
 passes under the lower edge of the transverse and  internal oblique
 muscles, and here it receives its second covering from the cremaster
 muscle.
   The abdominal ring  is closed by the intercolumnar fascia, and
 from this the cord also derives a third investment, termed the sperma-
 tic  or intercolumnar fascia;  and, in addition  to these several cover-
 ings, namely,—the funnel-shaped process of  the fascia transveisalis,
 the expansion of the cremaster,  and the spermatic or intercolumnar
fascia,—the cord is also covered  by the superficial fascia, placed
 immediately under  the integuments.
   These investments of the cord are also the coverings  of the com-
 mon bubonocele, or oblique inguinal hernia, which descends  through
 the inguinal canal.   The hernial sac has between its external  sur-
 face and the  inner surface of the cremaster the funnel-shaped pro-
 cess, or investment  derived from the margin of the aperture  in the
 fascia transversalis, and named in some schools the internal sper-
 matic fascia.  On  the  outside  of the cremaster, the  sac  has the
 covering derived from the intercolumnar;  and, external  to  this, the
fascia  superficialis, which is immediately under the common integ-
 uments.
   Sir Astley Cooper believes the inguinal canal to be endowed with
 muscular contraction, which, under the action of the abdominal mus-
 cles, serves  to  close it, and lessen the propensity to hernia.  He
 observes,  that the  lower edge of the transverse muscle  begins to
 be attached to Poupart's ligament  almost immediately  below the
 commencement of  the internal ring, and that  it continues to  be in-
 serted  behind the spermatic cord into Poupart's ligament as far as;
 the at'.achment of the rectus.   Sometimes, he has found'a  portion
 of muscle  descending from the tendon of the transversalis,   in the
 course of the linea  semilunaris,  to be inserted into the fascia trans-
 versalis, behind the cord, and into Poupart's  ligament,  and   a pre-
 paration exhibiting this conformation he was  so obliging as to show
 me some time ago.   Sir Astley believes, that this encircling of the
 internal ring and upper part of the inguinal  canal by muscular fibres,
 may be a cause of strangulation in the external bubonocele.   How-
 ever, the anatomical facts, on which  this  doctrine is founded, are
 sometimes  considered  to be only deviations  from what may be re-
 garded as  the normal, or most usual,  conformation of the parts.
 Although we may not be disposed to  explain  the  supposed spasmo-
 dic nature  of some  kinds of  strangulation by the cause  referred to
 by  Sir Astley Cooper, we ought to feel obliged to him  for  his ori-
 ginal explanation of the internal ring being occasionally  surrounded
 by muscular  fibres  derived  from the  transversalis.   His  greatest 
  SITUATION AND COURSE  OF  THE  SPERMATIC VESSELS.  189

discoveries on the subject of this hernia, however, appear to me to
be those relating  to the first correct description of the internal ring,
and of the fascia transversalis.
OF  THE  SITUATION  AND COURSE  OF THE SPERMATIC VESSELS
  AND EPIGASTRIC ARTERY,  IN RELATION TO  INGUINAL HER-
  NIA.

  As the epigastric artery naturally runs first behind  the spermatic
cord, and then about a quarter of an inch from the pubic margin ot
the internal ring, and as the viscera protrude through this aperture,
and follow the course of the cord, they  must  be situated  on the
outer side of that artery, which passes first behind the neck of the^
sac, and then at its inner side, in its way to the  inner surface of the
rectus muscle.   Hence, the inner margin of the neck of the sac is
encircled, as it were, by the track of the vessel.
   In recent  bubonoceles, the internal and external opening of the
ring are  at some distance from each  other, the  first being  situated
obliquely upwards and outwards  in relation to the former;  but the
pressure of the protruded viscera gradually forces the internal open-
ing more towards the pubes, and nearer to the abdominal ring,  so as
to render the posterior side of the neck of  the hernial  sac and of
the inguinal  canal very short.   Thus, in an  oblique inguinal hernia
of long standing, the opening into the abdomen is almost direct, and
the epigastric artery becomes situated  nearer the pubes than in the
natural state.
   But, though in the most frequent form of  bubonocele the protru-
sion begins at the  point  which I have  described, and  follows the
course of the spermatic  cord, passing all through the inguinal canal,
and having the epigastric artery  behind and  at  the inner margin of
the neck of the sac, circumstances are very different in another less
common variety  of bubonocele, where the viscera instead of begin-
ning to protrude at the internal and upper opening of the  inguinal
canal, and descending through that canal by following the course of
the spermatic  cord, are thrust out at the point  directly behind the
abdominal ring, together with the portion of the fascia transversalis,
forming, with the conjoined fibres of the internal oblique and trans-
verse muscles, the posterior boundary of the inguinal canal, imme-
diately behind the  abdominal ring,  out of which  the  viscera then
protrude in a direct manner.   Here the hernial  sac, instead of  pass-
ing over the spermatic cord, as in the most frequent form of bubono-
cele, lies on its inner or pubic side; and  the epigastric artery now
pursues its course in front of the neck of  the sac, at  the usual dis-
tance from the upper and outer angle of the abdominal ring.
   As in the most common inguinal hernia, the protrusion is on the
outside of the epigastric artery,which winds under and round the inner 
190
HERNIA.
margin of the neck of the sac, the case is sometimes termed the ex-
ternal bubonocele; while the less frequent one, in which the protruson
takes place  immediately behind  the abdominal  ring, out  of which
the viscera pass without  having  descended  through the rest of the
inguinal canal, is named the internal bubonocele; a case most par-
ticularly claiming recollection, as the protrusion is  at  the inner or
pubic side of the  epigastric  artery.  One  case is also  called the
oblique  inguinal  hernia;  and the  other the  direct or ventro-inguinal.
   In this internal  direct inguinal hernia, the  sac pushes out  with it
the fascia transversalis,.situated immediately behind the  ring, and
must either lacerate or displace the united fibres of the internal ob-
lique and transverse muscles at this point.   As  the hernia does not
follow the spermatic cord through the inguinal canal, in general the
cremaster only covers it near the abdominal ring.  With this excep-
tion, the coverings of the hernia are the same as in  the  external
bubonocele.
   The  explanation of the very different situation of the epigastric
artery, in relation to the neck of the sac of an internal bubonocele,
from what prevails in the external one, immediately shows how im-
portant  it is to distinguish one case from the other in practice.  In
fact, if  we were  to divide  the  stricture  in  the same way in each
case, we should often wound  the epigastric artery.   The discrimi-
nation of one case from  the other is also  important, with reference
to the manner of performing the taxis, and  the kind of truss that
should be selected.
   In scrotal  herniae of  large size, the spermatic vessels, instead  of
forming a cord,  may be disjoined by the pressure  of the swelling,
the vas  deferens being situated on one side of the sac, and the sper-
matic artery and veins on the other.  In general, towards the upper
part and neck of the sac, the cord  is not  much unravelled:  but,  as
its  component  vessels proceed  downwards, they  diverge more and
more, and spread themselves over the sides, or even over the front
of the sac.
   The  close adhesions, which a hernial  sac soon contracts to the
cellular substance on the  outside of it, makes its  reduction a rare
occurrence.  Such an  event, however, sometimes  happens, espe-
cially in the femoral  and internal bubonocele; for, in the   external
one, the prompt and intimate manner in  which the  sac becomes con-
nected  to  the  spermatic cord, makes it much less likely to  take
place.
   Bubonoceles  are most common in the male sex; but are occa-
sionally met  with in women, and  then  the  round ligament of the
uterus bears  the same relation to the tumor as the spermatic cord
does in males.   Of  course,  ifl such a case, the hernia has  not  the
covering which, in the male  subject, it  derives  from the cremaster.
There are also  rare examples in which the direct  bubonocele oc-
curs in  women.    I operated upon  a Mrs.  Smith for a strangulated 
OBLIQUE  AND  DIRECT  INGUINAL HERNIA.        191
hernia of this description, a tailor's  wife, in Cumberland  Street,
Middlesex  Hospital.   As she had  no stools for three or four days
when [ went to her, and the symptoms  were urgent, I  performed
the operation at  once, without  trying  any previous  means  but the
taxis, and,  in about a week, she was perfectly well.

DIFFERENCE  IN  THE  SYMPTOMS  OF  OBLIQUE,  AND  DIRECT
                       INGUINAL  HERNIAE.

   In the oblique inguinal  hernia, there  is '«n oblong  swelling, ex-
tending obliquely inwards and downwards; in the direct  hernia, the
parts pass  from  behind straight forwards, and form, on the  outside
of the abdominal ring, a circular globular swelling, in general  sud-
denly occasioned by some violent effort.   If any obliquity occur in
the direct  inguinal  hernia, it is in a course towards  the linea alba,
and  not towards the anterior superior spinous process of the ilium.
Then, in the oblique inguinal hernia, the spermatic cord  is situated
behind or under the sac;  but, in the direct bubonocele, it lies to the
outer side, or upon the external half of the front of the  neck of the
hernial sac.   In the direct  inguinal hernia,  where the sac adheres
to the cord, the testicle is not situated exac tly under the fundus  of
the sac, as in the oblique inguinal hernia, but either at the forepart,
or on the outer side of it.
   In the direct bubonocele, ihe epigastric artery ascends obliquely
inwards  at the outer side  of the neck of  the  hernial sac,  though
Hesselbach found an exception to this in one rare case, where that
artery proceeded from the obutratrix.   This hernia occurs w here
the tendon of the transversalis is unnaturally weak,  or from malfor-
mation does not exist  at  all, or  from violence has  been  broken.
Sometimes the  fascia  transversalis protrudes before the peritoneum,
and  there  may  be between the two membranes  a  stratum  of fat.
In certain  instances,  the hernia  neither distends nor lacerates the
conjoined  tendon, but the  protrusion takes place under  the edge of
the transversalis, and  then through  the lower opening of  the inguinal
canal.   Sometimes this hernia consists of two protrusions, divided
from each other by strong tendinous fibres.
   In other instances,  the fascia transversalis is lacerated, not dilat-
ed.   In general the  sac is  not  covered by the cremaster; but all
the  best authorities concur  in the statement,  that this investment is
not unfrequently met  with.  A direct  inguinal iiernia  is now and
then  accompanied  by an  oblique one.
   From the previous  description  it is  suffic'ently clear,  why, in
the oblique hernia, the pad of a truss should always press, not mere-
ly upon  the abdominal ring, but upon the track of the inguinal canal;
and  why, in the direct hernia, the pad should only act upon  the ab-
dominal  ring.   In  the taxis, the direction of the pressure >hould be
different;  for,  in the oblique  bubonocele,  the viscera  should  be 
192
HERNIA.
pushed upwards, backwards, and outwards; in the internal,upwards
and backwards.   Then, in the operation  on strangulated  cases, a
still  more  important  thing   to  be  remembered  is the  different
directions which should be given  to  the incision for  the  division of
the stricture: in the  oblique  case,  we  may cut upwards  and out-
wards, with perfect safety to the epigastric artery, but not inwards
or towards the linea alba; whereas,  in  the direct  hernia,  the cut
must not be made outwards,  but inwards, the epigastric not being
displaced from its  natural situation.   In order to avoid doing mis-
chief by mistaking one sort of hernia for another,  Sir  Astley Cooper
recommends the incision always to be made directly upwards.

         OPERATION FOR OBLIQUE INGUINAL HERNIA.

   The hair having been removed from the  parts which will be in
the track of the  knife, and  the bladder emptied,  the  first incision
should commence an inch above the  external angle of the abdominal
ring, and extend obliquely downwards, and inwards over the middle
of the tumor to its lower part except when the hernia is very large.
This incision divides the  skin and the  superficial fascia,  and some-
times the upper branch of the  external pudic  artery, as it crosses
the tumor near  the abdominal  ring.   By directing the incision ob-
liquely downwards and  inwards we lessen the chance of injuring the
spermatic vessels,  should they  happen  to  be situated towards the
front of the sac.   The  division of the integuments, subcutaneous
fat, and the facia superficialis, exposes the fascia derived from the
intercolumnar, at the abdominal ring, and generally forming one of
the thickest  coverings of the  hernia.   We should  then  make a
small opening through this covering derived from the intercolumnar
fascia, which may be safely done by taking hold of a small portion
of it with a pair of forceps, and then  dividing it cautiously close to
the point of the forceps, with the edge of the knife turned  horizon-
tally.   Having  made  an  opening,  we  introduce a director, and,
with a probe-pointed curved bistoury, divide the fascia  upwards and
downwards as far as the external incision reaches.   Thus  the next
covering  of the hernial sac is brought into  view-, namely, the expan-
sion formed by the cremaster,  which must  be  opened and divided
in the same manner as the fascia.  Having done this, we  come to
the funnel-shaped process, or the continuation of the  fascia  trans-
versalis between the upper portion of the cremaster and the hernial
sac, but which is so thin and so soon lost  in the cellular tissue be-
tween the sac and the cremaster, that it is not recognised by some
of the best writers  on hernia.   Now  the cellular  tissue  on the out-
side cf the sac will be brought into view; and, after having careful-
ly divided it, we arrive at the hernial safe'itself; a little piece of the
anterior and lower  portion of which is to be lifted up between the
thumb and fore-finger,  and carefully  examined to learn whether *hc 
OPERATION FOR OBLIQUE INGUINAL  HERNIA.
193
fold thus raised includes  any portion of bowel.   If it does not, we
take hold of it with a pair of forceps,  and cautiously open it  with
the edge of the  knife directly horizontally.   Surgeons choose to
open the hernial sac at its anterior and lower part, because if  there
be any fluid in it, it will gravitate to this part, and be a  kind of pro-
tection to the intestine from the edge of the knife.   Sometimes
much perplexity is evinced in distinguishing  the sac itself from the
intestine.   However, the circular arrangement of the  vessels of a
piece of  intestine,  and  its  smooth   polished surface, sufficiently
characterise it from the hernial sac, which has a  rough  cellular sur-
face,  bloodvessels  pursuing  an  arborescent  course, and is closely
ci .nected to the surrounding parts.   Having made an  opening into
the hernial sac,  we are to introduce  a director,  and, with a probe-
pointed bistoury, lay it open to the extent of the other  incisions.
   The next thing is to divide the stricture,  which may be situated
either at the abdominal ring, and be formed  by the margins of this
opening;  or else,  what  is more frequent, within the inguinal canal,
where it is produced by the lower edge of the internal oblique and
transverse muscles; or, lastly, at the internal ring itself, about an inch
and a half from the external ring,  in the  direction towards the  an-
terior superior spinous process of the ilium.
   If  the case require  it,  we may now introduce a director, or the
end of  the left fore-finger, into the neck  of the sac, within the ab-
dominal ring, and, with a probe-pointed bistoury,  cut  the stricture
upwards and outicardsor if it be preferred directly upwards; there-
commendation of which  last plan,  suggested as  a general one by
Sir Astley Cooper, is, that we shall not endanger the epigastric
artery by  it, whether  the case  be an external or an  internal bubo-
nocele.   Were  we completely sure, however,  that the case were
a direct  bubonocele, we  might safely divide the stricture upwards
and inwards, the epigastric artery lying on the outer side of the neck
of the sac, the reverse of what  happens  in  the oblique,  or most
common form of bubonocele.
   When the stricture is at the upper opening of the inguinal canal,
 the abdominal ring itself should  not be cut, unless it prevent the
operator from reaching the more deeply-seated strangulation.
   The next business is to return the  protruded parts,  if sound, and
free from adhesions; and  this will be considerably facilitated  by
bending the thigh, and rotating the  limb inwards.  Sometimes, it
is true, there is  a good  deal of difficulty in separating adhesions,
which may even be such as to  prevent  the  reduction of the pro-
truded parts altogether; but this is  unusual.   In  such  a dilemma,
by dividing the stricture, we render as much  service as surgery can
accomplish;  and the patient will not always be lost, though we may
be obliged to leave some of the bowels protruding.   The intestine,
if possible, should always be reduced, unless it  be found in a state
of actual mortification.   The appearance of  dark-brown chocolate
   VOL.  II.                   17 
194
HERNIA.
 discolorations is no objection; and  they should  be discriminated
 from the black or purple spots which indicate mortification.
   With respect to adhesions, the  intestines are not often firmly ad-
 herent  to  one  another.   In general,  the  strongest adhesions are
 those between the omentum and the inside  of  the sac.   Slight ad-
 hesions of  the intestine to the inside of the sac may be gently broken
 with the fingers.  If such connection should require the  use of the
 knife, the safest plan is not to cut too near the bowel, but to remove
 the  adherent  parts of  the sac, and return them  with the intestine
 into the abdomen.  But, if the adhesions should be within the neck
 of the sac, the inguinal canal should be more freely  laid open, so
 as to bring them into view.
   One important rule,  after the reduction, is, to introduce the finger
 tenderly, and ascertain that the parts are all fairly  and freely return-
 ed, and not suffering any  degree  of constriction, either from  the
 margin of the internal oblique and transverse muscles, or the inner
 opening of the inguinal  canal, or other causes,  and not  confined by
 any adhesive bands, formed across the mouth of the hernial sac.
   Treatment  of omentum.—In entero-epiplocele, the  omentum, if
 healthy, is  to be reduced after the intestine.  If much enlarged and
 indurated, or gangrenous,  diseased, or mortified, the  unsound  por-
 tion is to be cut off, and the arteries taken up with a tenaculum, and
 secured with fine thread or silk.   One  half of each thread  is to be
 cut off close to the knot.   I do not return the portion of omentum,
 that lies in  the  upper part of the  sac;  by which  means all  risk of
bleeding into the abdomen is avoided.
   Treatment of Mortified Intestine.—In many  cases, when the in-
testine mortifies in a hernial sac, (he latter part, its coverings,  and
 the integuments, also become gangrenous.   If  the patient continue
 to live,  the intestine  bursts, and the  feces at length find an outlet,
 either through the wound made by the surgeon, or an opening form-
 ed by the separation of the sloughs.   Of course,  before the bowel
 mortifies, the  neighboring  inflamed part of it becomes adherent to
the neck of the sac.   After  this  the  final  result  may  be of three
kinds:  either the death of the patient;  his recovery,  with the loath-
 some annoyance of an artificial  anus;  or the  gradual  diversion of
the feces from the wound to their natural  course again,  the  cicatri-
 sation of the part, and  a complete cure.
   The principal thing,  on which the re-establishment of the continu-
ous state of the intestinal canal depends,  is  the adhesion which  the
living portion of bowel, adjoining the mortified  part, contracts with
 the peritoneum all round.   In this manner,  the  escape of the con-
tents of the bowel into the cavity of the  abdomen  is in  general
completely prevented.   The  two ends  of the sound  portion, after
the sloughs have been thrown off, become  connected together
 through the medium of a membranous cavity, which previously con-
stituted  a  portion of the peritoneal sac.  The gradual contraction 
OPERATION FOR OBLIQUE  INGUINAL HERNIA.
of the wound closes the  membranous  cavity  externally,  and thus
the continuity of the canal is restored.  The  two ends,  however,
are not joined, so as to form an uninterrupted  cylindrical  tube, like
that of the natural gut; but they.are united at  an angle more or less
acute;  and the matter, which goes from one to the other,  describes
a half circle in the membranous  cavity, while the two ends of the
bowel  always lie  in a more or less  parallel manner by the side of
each other; the upper with its orifice directed towards the external
wound by the feces, so long as they take that  direction.   The low-
er is less capacious than  the upper.
   This account renders  it plain, that there must be a considerable
projection, or jutting angle, between the orifices of the bowel, di-
rectly opposite the communication between the cavily of  the intes-
tine  and that of the  semicircular funnel-shaped membrane, as it is
termed by Scarpa.  Now, it is this  projecting ridge, or angle, that
forms a material obstacle to the direct passage of the feces from the
upper into the lower portion of the intestinal  tube.   It constitutes
one  of  the chief hinderances to the cure of an artificial anus;  and
it is  destroying it with the pressure of a pair of forceps constructed
for the  purpose, that Baron Dupuytren's plan often succeeds in cur-
ing this loathsome affliction.   One of the blades of  the instrument,
which is blunt, being one line in breadth, is received into a groove
in the other, so that the jutting angle,'or l'eperon, as it is termed by
the French surgeons, is crushed, not suddenly divided, which would
afford no  opportunity for the adhesive inflammation.  The first blade
is passed  into the upper  part of the bowel, the second into the low-
er, and the instrument is then firmly shut  by means  of  a screw,
wh'ch connects the handles, and by which the degree of pressure
can be regulated.   The  adjoining  portions of the peritoneum unite
by the adhesive  inflammation; the jutting  angle  included between
the blades sloughs; the cavity of the peritoneum is saved from an
effusion of intestinal matter into it;  and the canal of the  bowel re-
mains free and perfect.   Much of the danger of an  artificial anus
will  depend upon its degree of nearness to the stomach.   Thus, if
the opening be  in the jejunum, there  will be so small  an  extent of
surface  for the absorption of chyle, that the patient will die of in-
anition.
   If mortification of the bowel be first detected on opening the sac,
and  there should  be only  one or two spots, we are to  divide the
stricture;  and, if the gut be not adherent, it is to be reduced.
   When the chief part, or the whole diameter, of the bowel is mor-
tified, the indication is to make an outlet for the intestinal matter, by
a free incision through the sloughs, and by cutting the stricture if it
should  still exist.   Here,  of course, all  idea of reduction of  the
parts is  out of the question.
   In operating upon very large hernia of long standing, the proper
plan  is to  divide the stricture, if possible,  without  laying  open  the 
196
HERNIA.
hernial sac.   The plan will answer, if the stricture be at the ab-
dominal ring.   When the sac must be opened, it should be so only
towards the latter opening, and not more  extensively than circum-
stances demand.   The free exposure of the cavity of a bulky her-
nia is itself a frequent source of fatal mischief.
   In operating upon hernia within the inguinal canal, but not pro-
truding through the ring, we should  make the  incision in the direc-
tion of that canal.   In such a case,  the stricture  will be found at
the internal ring.
   After the  operation, the wound is to be  closed  with a suture or
two, and lightly dressed.  Evacuations  from the  bowels are to be
promoted by means  of small doses  of  sulphate of  magnesia, dis-
solved in peppermint water, or by clysters.  The  patient  must not,
however, be allowed to sit upon the night-stool, as doing so would
be likely to bring on a protrusion of the bowels again.   It is safer
to put a bed-pan under him.  If tenderness and tension of  the belly,
with costiveness and  febrile symptoms, come on again, in the course
of a day or two, we  must have recourse to local and general bleed-
ing, poppy-head fomentations, and castor oil.   If the stomach be
much disturbed after the operation, the sulphate  of magnesia may
be given  in the effervescing  saline draught, with or without a few
minims of the tincture of  opium or hyoscyamus.
   Before the patient leaves his bed, a truss is to be  applied.
   When the  bowel has been much discolored, it will sometimes
give way two or  three days after the patient has  appeared to be
going on well;  and the patient is destroyed by peritonitis, resulting
from effusion of the  contents of the  bowels into the cavity of the
peritoneum.

         OPERATION FOR  DIRECT  INGUINAL  HERNIA.

   In this case, the coverings of the  sac are the skin and superficial
fascia, the intercolumnar fascia, the fascia transversalis, and  some-
times the  tendinous  fibres of  the internal oblique and  transverse
muscles, if  not torn  or burst.   It is only in the vicinity of the ab-
dominal ring, that this hernia commonly has any  fibres of the cre-
master spread over it. ^ The several investments, here   specified,
are to be divided much in the same way as those of the oblique bu-
bonocele, and the  stricture cut, either upwards and inwards, or di-
rectly upwards, as preferred by  Sir  Astley Cooper, for  a  reason
already explained.

              THE FEMORAL OR CRURAL HERNIA

Is so called, when the hernial sac and  its contents protrude under
Poupart's ligament at the inner side of the femoral vein, so as to
be situated  in the  bend of  the groin, upon the  pectinalis muscle, 
THE FEMORAL  OR CRURAL HERNIA.
197
 between the gracilis and  sartorius.   The protrusion  takes place,
 in fact, through the crural or femoral ring into that compartment of
 the crural sheath which is destined for the passage of the absorbent
 vessels of  the  lower  extremity.   When  once the sac has descend-
 ed as low as the saphenous  opening in the fascia  lata, the hernia
 has more room to extend itself forwards,  and to each side,  and  the
 integuments now  become raised into an  oval  swelling, the great-
 est "diameter of which is nearly transverse.
   The femoral hernia is frequent  in women* who have had children;
 but  rare in young girls.   In men, a  hernia more  readily forms
 through the inguinal canal, by following the course  of the spermatic
 vessels, than under  Poupart's ligament;  but the latter case  is far
 from being so  uncommon in them as sometimes represented.
   The tumor, produced  by a femoral  hernia, may be  mistaken for
 an enlarged gland.   A gland can  only  become  enlarged by  the
 gradual effects of inflammation; the swelling of a femoral hernia
 comes on suddenly, and, when strangulated, occasions  the  train of
 symptoms  already  described, which an enlarged gland could never
 occasion.   As my friend,  Mr.  Morton, also correctly  observes,
 in consequence of the extensible and yielding  nature of the deep
 lamella  of the superficial femoral  fascia, glandular  swellings  are
 readily moved upon their basis by lateral pressure, and even allow
 the tips of the fingers to  be pressed underneath them, so as to lift
 them  up,  as it  were,  from  the fascia of  the thigh.   On  the  other
 hand, the neck of the tumor,  formed by a femoral hernia, is deep-
 er and more fixed.
   When the expanded part of a  femoral  hernia lies over Poupart's
 ligament, it may be mistaken for  a bubonocele;  but, the true nature
 of the case may always be made  out by observing, that the  neck of
 a femoral hernia has Poupart's ligament above it.   In  the bubono-
 cele,  the spine of the pubes is below and behind the  neck of  the
 sac; but in the femoral hernia, it is  on the same horizontal level,
 and a little on the inside of it.
   When a  femoral  hernia expands   in  the  bend of  the thigh, its
 shape is oval,  and its greatest diameter  is placed transversely; but,
 whatever may  be the size of  an  oblique  inguinal hernia, it has an
 oblong pyramidal  shape, with its fundus  not  inclined towards  the
 ilium, but in the direction of the spermatic  cord towards the scrotum.
   Besides  the  symptoms, common  to all  hernial swellings, the  fe-
 moral hernia, when of a certain size, has  some which are peculiar
 to it,  as  stupor, and  sense of weight in the  thigh,  and sometimes
oedema of the leg and  foot:  circumstances,  accounted for  by the
   A large proportion of the patients, on whom I have operated, were old women
One, on whom I operated toward, the end of October, 1839, i„ University ConTe
Ihnpital, was eg luy-seyen, and is at tliis date (Nov. 2. 1839) nearly well  I remem
ber no instance where the operation was performed on a subject of this very advanced
age
                            17* 
198
HERNIA.
pressure of the hernia on the bloodvessels, lymphatics, and nerves,
which pass out of the pelvis in its vicinity.

          SURGICAL ANATOMY OF  FEMORAL  HERNIA.*

   The  crural arch is  a term applied  to the  lower margin of Pou-
part's ligament,  the space intervening between which and the ilium
and os pubis is,  in a great measure, closed on the side towards the
abdominal cavity by  the union of  the  iliac and transverse fascia
at Poupart's ligament, which fascia?, in  fact, shut up all that space
which is between the  anterior superior spinous process of the ilium
and  the femoral vessels.   Hence, a  hernial  protrusion  scarcely
ever happens in the space below the crural  arch to the  outside of
the femoral artery and vein.   The  occurrence is prevented not on-
ly by the junction of the iliac and transverse  fascia? within, but also
by the fascia lata without, which, in  this situation,  is strong and
closely  attached to the subjacent  parts.   The femoral hernia takes
place through the crural ring, a small  oval aperture, which is situ-
ated under the crural arch,  more towards the pubes; in fact,  be-
tween the thin posterior border of  the  crural  arch, termed  Gim-
bernaVs ligament, and  the septum at  the inner  side of the femoral
vein.
   As the protrusion does not take place through a simple aperture,
but follows a course of some trivial length,  the  expression crural
canal is employed by  Scarpa and  Cloquet.   It is at  all events the
superior or posterior aperture  of the crural canal which  is implied
by the crural ring,  the canal itself extending obliquely downwards
and forwards for a half or three quarters of  an inch, and  terminat-
ing below at the oval  depression for the vena  saphena major; or,
in the words of Mr.  Morton, the crural  canal, is the short passage
which extends between the saphenous opening of the fascia lata and
the crural ring.  It is formed by  the  innermost of the  compart-
ments into which the funnel-shaped sheath of the femoral vessels is
subdivided.
   The  viscera descend at first nearly in a perpendicular direction,
and  come into the hollow in  front of the  pectinalis, but  the hernia
then turns forwards, and  directs itself  rather towards the ilium, the
fundus  of the sac  sometimes inclining over the crural arch.
   As the protrusion descends over the pectineal line, or close at-
tachment of the  pectinalis muscle to the pubes,  it must be situated
over the pubic portion of the fascia lata,   GimbernaVs ligament,
which is a part  of so much  importance  in the anatomy of femoral
  * An excellent description of this  subject, which I recommend to all students, is
contained in " Morton's Surgical Anatomy of the Groin, the Femoral and Popliteal
Regions."  8vo. Lond.  1839. The lithographic plates and wood engravings are
superiorly executed from original drawings; and the book is replete with valuable sur-
gical remarks. 
SURGICAL ANATOMY  OF FEMORAL  HERNIA.
hernia, I think,  will be best understood by considering it as a pro-
longation or extension  of  Poupart's ligament, which,  when  it ap-
proaches the os pubis, becomes suddenly broader,  and is attached
by this broad portion to the angle and crista of that bone, and lleo-
pectineal  line.  The  posterior edge of Gimbernat's  ligament is
concave, thin, and sharp, the ligament itself about three quarters of
an inch in breadth, but broader in the male than the female subject.
In the erect position of the body, it is nearly horizontal.
   The crural ring,  through which  the absorbents of the thigh as-
cend to the lymphatic glands situated upon the inner border of  the
psoas muscle, is formed by this posterior edge, or, as  it is some-
times termed, the base of  Gimbernat's ligament,  directed  towards
the crural vein; externally by the femoral vein, or rather by a pro-
duction of fascia, or a kind of septum placed between that  vessel,,
and the compartment of the femoral sheath,  through which ascend
the great lymphatics of the thigh;  anteriorly by the thin posterior
edge of the crural arch, or Poupart's ligament;  and posteriorly by .
the horizontal branch of the  os pubis.   But  into  the crural ring
productions both of the fascia transversalis and fascia  iliaca always
descend,  so as to form at once a part of the tubular or funnel-shap-
ed sheath for the femoral  vessels, and a lining for  the crural  canal,
the  front half being  formed by the fascia transversalis—the back
by the fascia iliaca;  and, as Sir Astley Cooper has clearly  explain-
ed,  it is through the inner side of the sheath, next to the pubes,
that the femoral absorbent vessels pass into  the abdomen, the open-
ings for which give a cribriform appearance  to this portion of the
tubular sheath.  The femoral sheath is wider above than below:  its
external side, which is straight, being closely applied to the femoral
artery; while  its inner margin  extends  downwards and outwards
from Gimbernat's ligament to  the  femoral vein, just on  the inner
side of which vessel is an  oval aperture, frequently occupied by a
lymphatic gland, and some absorbents and loose cellular tissue (the
septum crurale of J.  Cloquet), through which opening the hernia,
in its descent, passes towards the point of the fascia lata, at  which
the vena saphena major gets to the femoral  vein, which point is in-
cluded within what is called the falciform process.   It  should then
be clearly understood,  that the tubular or funnel-shaped sheath  of
the femoral vessels is subdivided into three  distinct compartments
•by the membranous  septa, which are  situated on  each side of the
femoral vein,  and connect the anterior and posterior parietes of the
sheath more firmly together.  The most external  of these subdivis-
ions  contains the common femoral artery,  the second, or middle,
the great femoral vein, while the third, or that which is nearest  the
tuberosity of the os  pubis, corresponds with the crural ring, and is
closed in the natural condition of the  parts  by some loose cellular
tissue, and  lymphatic vessels, an absorbent gland also  occasionally 
200
HERNIA.
lying within it.*   Into this last compartment, the viscera  protrude
in a femoral hernia.
   The very lucid and original explanations  of  the  anatomy of fe-
moral hernia by  Sir  Astley Cooper reflect the  highest  honor on
himself,  on bis profession, and,  I would also say, on  his country.
We knew little  about various  points in the  minute  anatomy of
femoral hernia until he demonstrated  them, and  published  a clear
description of them.   If we turn to this source of information, or,
what is better, if we  dissect  and open the tubular sheath, we  find
that it contains two membranous partitions, or septa, one passing
between the artery and vein,  and  another  between the vein and
the absorbents.   The artery and vein completely fill up the spaces
in the sheath allotted  to them; but the absorbents, being but loosely
connected by cellular tissue, do not always afford sufficient resist-
ance to prevent the descent of the viscera in this  situation, and the
formation of a crural hernia.  It  is this opening, then, in  the inner
part of the sheath, which  is really the aperture by which the bow-
els descend, and which  is situated,  as  already  stated, between the
thin crescentic  edge of the base of Gimbernat's ligament and the
femoral vein, or  rather the septum.   Or I may say, that the hernia
protrudes into the division of the tubular  sheath, designed  for the
transmission of  the  principal trunks  of the absorbents  from the
lower extremity, scrotum,  and superficial  parts of the  hypogas-
triac  region into the pelvis.
   The falsiform process  is easily comprehended when  we remem-
ber, that the fascia lata has two origins, one from the lower border
of Poupart's ligament, all the way from the anterior superior spinous
process  of the ilium,  to the tuberosity of the  os pubis.  This, which
is the thickest and strongest, is called the iliac portion, and it cov-
ers the psoas, iliacus, sartorius, and rectus muscles, the femoral ar-
tery and vein, and the anterior crural  nerve, its breadth in the adult
subject being from four to five inches.    The inner or pubic por-
tion of the fascia lata arises  from the pubes  in front of the origin  of
the  pectinalis  muscle,   which   muscle  it  covers, together  with
the adductor longus,  and the gracilis,  and afterwards unites with the
 iliac  portion of  the  fascia lata,  under the great saphena vein.   Of
 course,  it lies  behind or under the  femoral  vessels,  while the  iliac
 portion  is in front of  them; and above, it is continuous with the iliac
 fascia.   From this description, it is manifest that, where the pubis
 portion  of the fascia lata joins the iliac portion under the vena saphe-
 na major, there  must be an aperture left for  the passage of that ves-
 sel.   This opening  is termed the saphenous opening, the concave
* See Th. Morton, Op  cit. p. 90. 
SURGICAL ANATOMY OF FEMORAL  HERNIA.
201
external margin of which consists of part of the falciform process,
first correctly described by Mr. Allan Burns.*
   Scarpa represents the iliac portion of the fascia lata as connected
with Gimbernat's ligament; and Mr. Lawrence  describes the upper
end of the fascia falciform process, not merely as passing in front of
the femoral vessels, just as  they  emerge from behind  the crural
arch, but  as bending under  Poupart's ligament, so as to unite with
the thin border of the  arch called  Gimbernat's ligament.
   The great saphaenal vein   passes over the inferior sharp  edge or
horn  of the  falciform  process, and there joins the femoral vein.
Then, between the parts just described and the skin, is the jascia
superficialis, quite distinct from the fascia lata, and consisting of two
layers, between which lie some adipose  matter and the superficial
inguinal glands.   Where it  covers  the saphenous opening,  it has
several apertures in it, and  this portion of it, or rather  of the deep
layer of it,  is sometimes termed the cribriform fascia.f
   The anterior wall of the crural canal is formed by the  fascia trans-
versalis, covered  by the falciform process of the iliac portion of
the fascia  lata.  The  posterior wall is formed  by  the  fascia iliaca,
supported on the pubic portion of the fascia lata, which here covers
the-pectineus.   The external wall is formed  by the septum at the
inner side of the femoral vein, and the internal  by the transverse
and iliac fasciae, where they unite  to complete the inner side of the
funnel-shaped sheath.
   In femoral  hernia,  the viscera  descend through the  crural  ring,
pushing before them the peritoneum.   They then  pass into the in-
ternal compartment of the  tubular  sheath of the femoral vessels,
that designed for the transmission  of the lymphatics, and afterwards
turn forwards, and even upwards,  through the  saphenous opening in
the fascia  lata,  so as to lie over the iliac portion of the  fascia lata.!
   The coverings  of the femoral  hernia  are  the integuments, the
fascia superficialis, and the fascia propria, or tubular sheath of the
femoral vessels, besides the  peritoneal hernial sac.   The epigastric
artery passes  obliquely upwards and  inwards, about  half an inch
from the external  side of the neck of the sac.  Wrhen the obtura-
  * " It is in a great measure owing to the connection existing between the margin of
the saphenous opening and the sheath of the vessels, that the fundus of the sac of a
complete femoral hernials usually prevented from descending any further downwards,
butts rather turned, or tilted forwards and upwards, so as to rest upon the falciform
process under the lower part of the aponeurosis of the external oblique muscle."
Morton, Op. cit. p. 110.
  t " The fascia cribriformis adheres pretty closely to the margins of the saphenous
aperture of the fascia lata;  il is covered externally by the  cutaneous vessels and su-
perficial absorbent glands; while its internal surface  is in apposition with the anterior
part of the funnel-shaped sheath of the vessels, where it is formed by the lascia trans-
versalis."  Morton, Op. cit. p. 103.
  X In a few instances, where  the septum  on the inner side of the femoral vein is
defective, the hernia, instead of protruding at the saphenous opening, descends further
into the sheath of the femoral vessel, and then, of course, it lies under the fascia lata. 
202
HERNIA.
 trix artery arises from the epigastric, it may go either near the outer
 or inner side of the neck of the  sac  to  the obturator foramen.
 When the common trunk of  these vessels, so originating, is  long,
 and the  place where the  obturatrix goes off from it  is high up, the
 latter vessel may descend near the  upper and inner border of the
 crural ring.   But,  when it  arises from the  epigastric lower  down,
 it will then pursue  its  course downwards near the external margin
 of the neck of the sac.   On this point, Mr. Morton makes the fol-
 lowing«remark:—" When the obturator artery is given off  from the
 epigastric  (a  variety that occurs  about once  in three  subjects), it
 most frequently descends upon the pubal side of the external iliac
 vein  to reach the  thyroid foramen; and, when it does so, will al-
 ways be placed upon the iliac, or external  side of the crural  ring,
 and therefore altogether  removed from  the  edge of the knife, as
 commonly directed in the operation for femoral  hernia."   Some-
 times, however, it  runs, for a short distance, along the  superior
 margin of the crural ring,  and  then descends behind  the lunated
 border of  Gimbernat's ligament, in its way to  the thyroid foramen.
 When this latter arrangement prevails, the neck of the hernial sac
 is surrounded  for  at least  three  fourths of its  circumference, by
 large and important vessels.   The  spermatic  cord, or, in women,
 the round ligament, as it lies within the inguinal canal, passes direct-
 ly over the superior part of the hernia; or, in other terms, is situat-
 ed close above the anterior margin of the  crural ring.   All these
 are  essential  things to  be considered in operating on  a femoral
 hernia.
   The peritoneum, as  it descends  before  the hernial  protrusion,
 pushes before it the subserous cellular  tissue, and the septum cm-
 rale.   So  long as the hernia is lodged within the crural  canal, and
 does not project through the lower opening of it, the case is termed
 an  incomplete femoral hernia.    On account of the tumor  being
 small, and bowed  down by the  falciform process, its detection, as
 Mr. Morton justly  observes, requires much attention, especially in
 corpulent subjects.
   When  the fundus of  the sac protrudes  through the  saphenous
 opening, the case is a complete femoral hernia.

      OPERATION  FOR  STRANGULATED  FEMORAL HERNIA.

   The bladder should first be emptied; for, a wound of it has been
 known to occur in the operation.  This is not always performed in
one way, different surgeons having different  modes of proceeding,
 according to their view of the parts chiefly concerned in forming the
 stricture, and of the safest place  for the incision, with reference to
 the epigastric artery and spermatic vessels;  for the round ligament
 in the female ought not  to have much influence on the question, a
 wound of it being of little importance.  At  St. Bartholomew's, the 
     OPERATION FOR STRANGULATED  FEMORAL HERNIA.  203

school where I was brought up, the surgeons usually began the ope-
ration by making an incision, which commenced about an inch above
the crural ring, or pubic portion of Poupart's ligament, and extend-
ed obliquely  downwards  and  outwards over the centre of the swel-
ling.   This plan answered very well where the intention was to di-
vide Gimbernat's ligament near the pubes, in order to free the pro-
truded parts from strangulation in the crural ring  itself, and to be
able to reduce them.   Sir A. Cooper and Baron Dupuytren make
two  incisions through the integuments, in the  form of the letter T
reversed.  The transverse cut, extending over the middle of the tu-
mor, is safely made by pinching the skin into a fold in the direction
of the femoral vessels, and then cutting it across.   The second in-
cision  is then to descend  from a little above Poupart's ligament to
the central part of the transverse incision, after which the angles or
flaps are to be carefully dissected  up.   The first transverse cut  is
likely  to wound the superficial epigastric artery: but this is a matter
of  no importance.   The division of the integuments exposes the
superficial fascia,  which  is here  generally thicker than  what lies
over an inguinal  hernia, though,  in thin persons and recent cases,
it may  be  so  delicate  as  to escape  notice.  It also includes
between its  layers the superficial absorbent glands.   Sometimes,
when we have made the incision through the skin, we find the hernia
concealed by dense fat and enlarged absorbent  glands;  but  we are
not  to be perplexed  by  the  circumstance, provided  we are  clear
and  certain respecting the existence of hernia.   I remember being
sent for to a poor woman in  St. Giles's, one twelfth-night, for  a
strangulated  femoral  hernia,  when, as the symptoms were urgent,
and  1 had not much time to spare on account of a private  engage-
ment,  I proceeded  to the operation directly after the taxis had fail-
ed.  Now, on making the incision through the integuments, I came
to such a mass of diseased fat and glands, that I was a little stag-
gered, and led to consider for a minute or two whether 1 might not
have been in too great a  hurry to operate, and  mistaken a  case of
enlarged glands for a  hernia.   But a little reflection convinced me,
that  the patient's symptoms could not  depend upon the latter cause;
and, on dissecting more  deeply,  I came to the  fascia propria of  a
small hernial tumor.   The patient recovered, as, I  think, most
patient's do,  in whose cases the operation  is not deferred  till  too
much inflammation and other  mischief have had time to  take place.
After the division of the  superficial fascia, we come to  the tubular
sheath of the femoral vessels, or fascia propria.  Our next  object
is to lay open the fascia propria, first lifting up a piece of it  with
the forceps, and then  making  a small opening in it  with the edge of
the knife directed horizontally.  A director is then to be introduced
into the aperture so made,  and  the fascia propria divided upwards
and downwards to the neck and fundus of the sac.  After  having
laid  open the fascia  propria, we may meet with a quantity of fat, 
204
HERNIA.
which, in  consequence  of the  long  pressure  of trusses,  some-
times presents a thickened  dense feel, and assumes very much the
appearance of indurated omentum, so  as to cause  an erroneous
suspicion  of the  hernial  sac  having  been  already  divided,  fol-
lowed by  pernicious efforts to push back the parts into the ab-
domen.  This is a subject, on  which excellent practical informa-
tion is contained  in Key's edition of Sir Astley Cooper's work on
Hernia, who has given a plate exhibiting an unopened  sac  pushed
back into the abdomen, with the strangulated bowel in it.  In Univer-
sity College Hospital, I operated last winter (1838-39)on a woman of
sixty, for a strangulated  femoral  hernia of long standing.   On open-
ing the fascia propria, a  portion of a cyst, imbedded in fat, and fill-
ed with fluid, presented  itself,  looking very much  like a fold of in-
testine.  On dissecting  more  deeply, another  cyst of  the  same
kind was met with, before the  hernial sac was exposed.*  Circum-
stances of  this kind, if the surgeon  be not aware of their possibi-
lity, create much embarrassment in the operation.   The hernial sac
having been  exposed, is now  to be  cautiously  opened, in which
step of the operation we are to nip  up a small  portion of the fun-
dus of the sac, and feel that no portion of the contents of the her-
nia is directly within it.   Then  we are to take hold  of it with the
forceps,  and make a small opening in it with  the edge of the  knife
directed  horizontally, and kept close to the extremity of the forceps.
On  this  being done,  a  certain  quantity of clear or turbid  serum
mostly gushes out, but not invariably.   The director is now to be
introduced, and the sac laid open upwards and  downwards to the
crural sheath and fundus of the sac  itself.
   Having  proceeded thus far, we may sometimes easily return the
contents of the hernia without the further use of the knife; but, un-
less this  be practicable without any squeezing and bruising  of the
parts, the  stricture ought to be cut.    In  this important stage of the
operation, I have generally divided  Gimbernat's ligament, and with
it the neck of the hernial  sac, and the  contiguous part of  the fas-
cia transversalis.   A  director  is introduced  along the inner side of
the protruded viscera  into the  crural ring, with  the groove  turned
towards the pubes.   Then with a narrow  probe-pointed bistoury,
or with Sir Astley Cooper's hernial bistoury, which  has but a lim-
ited cutting edge, and none at  all towards  the handle, in order to
occasion less risk of  wrounding the bowel, we are to cut the base or
deep-expanded part of Gimbernat's ligament in the  direction in-
wards, or  inwards and upwards.  In this^part of the operation, the
bowel is   continually  exposed to injury, on  account of the  small
space in which we have to act; and 1  recommend all  surgeons,
  * See Clinical Lecture in Lond. Med. Gaz. for March, 1839.  Cysts of this de-
scription I find noticed in the last edition of Lawrence's Treatise on Hernia; also by
Sir Charles Bell, in his Illustrations of the Great Operations of Surgery, p. 41. 
OPERATION FOR STRANGULATED FEMORAL  HERNIA.  205
therefore, not  only to use  the kind  of bistoury suggested  by Sir
Astley Cooper for the division  of the stricture, but to be particular in
keeping the intestine out of the way of the instrument with the left fore-
finger, or with the  hand of an assistant.   Of late, I have sometimes
cut the posterior edge of Poupart's ligament upwards and  inward
either with a common probe-pointed bistoury, or Sir Astley's knife,
passed along the nail of  the fore-finger of the left hand, which is
sometimes safer than a director.   " The  tip of the  finger  nail (as
Mr Morton  observes)  should be  insinuated  underneath  the band
which forms the stricture,  and  the  blunt extremity of the probe-
pointed bistoury (placed  flat upon the finger) guided just within the
sharp margin of the  stricture; after which the edge of the knife is
to be  turned  upwards and  the  handle being raised, the tendinous
band,  which resists the return of the bowel, will be easily divided."
The stricture having been  divided, the thigh should be fixed,  and
rotated inwards, in order to relax still  further the  crural ring, and
facilitate the reduction.
   When the  bowel  has been  strangulated beyond  a certain time, it
becomes dark-colored; and, though not actually gangrenous at the
period of the operation, it will sometimes give way afterwards.  This
happened in a case, where I  operated rather  too  late on the sister
of the celebrated  harlequin,  Bologna.   She  was a dancer, a pro-
fession particularly exposed to the risk of hernia.  After the  opera-
tion,  her sufferings ceased, she had several  motions,  and her pulse
came down to 80; but, all on a sudden,  forty-eight hours after the
operation,  she was seized with excruciating agony in the abdomen,
faintings, quick faltering pulse, and  cold  sweats, with  which symp-
toms she soon died; and, on opening her, it was found that a small
point of  the ileum had given way, that the  contents  of the bowel had
become effused, and that a rapidly fatal inflammation of the  perito-
neum had been the consequence.
   It would not be safe to cut the crural ring upwards in a male sub-
ject; because we should wound the spermatic cord.  In a female, how-
ever, in whom  we find that this hernia is most common, I do not know,
that the  round ligament ought to deter us from cutting in this direc-
tion,  if we  had any  reason for selecting it.   We could not  cut up-
wards and  outwards, because we should injure the  epigastric artery;
and we could not  turn the edge  of the  knife precisely  outwards, or
in the direction away from the pubes, because we should wound the
femoral  vein.   The safest  plan, therefore, seems to be  generally
that of making the requisite  division  of the crural ring by cutting
inwards  and a little upwards.
   The only case, in which the  division of the deeper part  of the
stricture, in the direction inwards, would be attended with danger
is that in which the obturatrix  artery arises from the epigastric, high
up, and, in  its way i ito the pelvis, descends round the inner margin
of the crural ring,   This position of the obturatrix  artery, however
in relation to the neck of the  sac and  the crural ring, is computed
   vol.  n.                   18                          r 
206
HERNIA.
not to occur more  frequently  than once  in  about eighty cases of
femoral hernia.   The  division 'of  Gimbernat's  ligament inwards
has not the sanction of some surgeons,  for  whom  I entertain the
highest  respect; and though it is the method which I have frequent-
ly adopted, and found answer,  let not the reader  suppose that  I do
not see reason for  sometimes following  other plans.   Sir Astley
Cooper cuts  the anterior part  of the crural canal, by carrying the
knife as far as the front margin of the crural arch, in the  direction,
upwards and inwards.   When  this is not sufficient, he next cuts the
thin posterior border of Poupart's ligament in the same direction.
there ought, indeed,  to be some variety in the method of operating,
according  to  the  circumstances of each individual  case: and  the
valuable investigations of  that eminent surgeon tend  to prove, that
the  seat of strangulation  in femoral  hernia  is not  always  in the
same place, but may be either in the crural sheath, where the stric-
ture is occasioned by the semilunar edge  of the fascia lata, or  the
saphenous opening, or at the posterior edge of the crural  arch;  or,
lastly, at  the   mouth of the hernial sac, in the  fascia  which  sur-
rounds  it.*
   Having  laid open the hernial  sac, Sir  Astley Cooper introduces
his probe-pointed bistoury, which does not cut near the point, into the
crural sheath, at the  anterior part of the sac, and  divides with it the
sheath as far as the front edge of the crural arch.   This cut, which
does not exceed half an inch, is sufficient for the reduction of small
hernia.   But if the bowel cannot now be returned by gentle pressure,
he passes in his finger  about half an inch higher, and divides the
posterior edge of the crural arch and fascia transversalis immediately
next to it.   As these two incisions are made from  within the  sac,
they will of course remove  any stricture formed  by  the sac itself.
The direction of an incision for the division of the stricture, which
he deems most eligible, is upwards, with a slight  obliquity towards
the umbilicus.
   Baron Dupuytren, in operating on femoral hernia, used to divide
the same parts as Sir Astley Cooper; but employed a curved probe-
pointed bistoury, which cuts on its convexity; it is  introduced into
the hernial sac flat on the left fore-finger, and its  edge is  then turn-
ed upwards and outwards, and the upper extremity of the falciform
process divided as far as the front margin of the crural arch.  Hes-
selbach also regards an incision through the front side of the crural
canal safer than one  through Gimbernat's ligament.   Although Du-
puytren directed  the  knife towards the spermatic cord, he did no
  * On this interesting part of the subject, the following is Mr. Morton's statement.
" In by far the greater number of instances, the consttiction is relieved by the division
upwards and inwards of the falciform process of the fuscia lata, and the lunated edge
of Gimbernat's ligament, where  they join with each  other.  In  some  instances, it
will be the fibres of the deep crescentic arch ; in others again the neck of the sac it-
self," within the circumference of the crural ring. 
CONGENITAL INGUINAL HERNIA.
207
injury to it;  because he took care not to cut far enough to endanger
it.  He also avoided the epigastric artery by making a very limited
cut.

               CONGENITAL  INGUINAL  HERNIA.

  The great peculiarity of this case is, that the protruded  viscera
lie in  the  tunica vaginalis,  which serves as the hernial sac.  The
bowel, or omentum, is therefore in contact with the testicle.
   The  congenital  inguinal hernia, arises in the  following manner:
In the foetus, the testes are  situated immediately below the kidneys,
on the forepart of the psoas muscles, with their anterior and lateral
surfaces covered by reflected peritoneum,  and their posterior sur-
faces connected to the psoas  muscles by  means of cellular tissue.
About a  month or six weeks  before birth,  but sometimes subse-
quently to this event, the testes descend through the abdominal ring
into the scrotum, where there is a production of the peritoneum al-
ready formed for their reception, and afterwards constituting the tuni-
ca vaginalis.  The testes in their descent do not fall loose into the
tunica vaginalis,  but  carry  with  them the peritoneum immediately
adherent to them.   Soon after the testes have got into the scrotum,
the upper part of the tunica vaginalis is closed, by which change all
communication  between the cavity of that membrane and the belly
is shut.   Sometimes, however, this closure is delayed, and then, if
any of the bowels insinuate themselves into the passage, they become
of course, so long as  they continue  unreduced, an impediment to
its further obliteration;  and  the case is a congenital inguinal hernia,
which differs from all common hernia in  having no hernial sac pro-
duced by  a protrusion of the peritoneum  with the bowels them-
selves.
   No doubt, one of the most frequent predisposing causes of con-
genital hernia is  the occasional delay  in the descent of the testicle,
which circumstance has  the  effect of retarding the closure of the
passage between the belly  and the scrotum.   The  disease is  not
generally produced by the insinuation of the  bowel into  the tunica
vaginalis at  the  same time as the   testicle itself.  Before  birth, the
small intestines are but little distended; and, in the absence of res-
piration, they can suffer no  compression from the diaphragm and
abdominal muscles.   Hence,  notwithstanding the expression  con-
genital, the disease  is  hardly ever noticed in infants directly they
are born, but makes its first appearance afterwards.   One acciden-
tal circumstance, however,  may really make the hernia strictly con-
genital, namely,—the  intestine or omentum  may  become adherent
to the testicle  previously to its leaving the abdomen, and consequent-
ly descend with it into the scrotum before birth.
   The formation of such adhesions between the bowels and testicle 
208
HERNIA.
before birth may also sometimes prevent, or retard, the descent of
the latter organ.
   Surgeons are frequently  consulted for congenital hernia, where
the testicle has not yet descended through the ring.
   The congenital  inguinal hernia must always necessarily be exter-
nal, or oblique;  because the neck of the tunica  vaginalis invariably
corresponds to the point, at which the spermatic cord  passes under
the border of  the transversalis muscle.   Also, as the tunica vagina-
lis enters the inguinal canal beyond the point at which the spermatic
cord crosses the epigastric artery, it must have this artery on the in-
ternal side of  the inner  ring.
   In young children, the congenital hernia more frequently contains
intestine  than  omentum, because in  them the latter  part  is very
short.  •
   The impossibility  of  feeling the  testicle,  while the  bowels are
down,  is  the most  important criterion between this hernia  and a com-
mon bubonocele, where we can always feel the testicle at the lower
and back part  of the swelling.   Then a  suspicion of the nature of
the case  may be entertained, if the  hernia has existed  from early
childhood; not that infants may not  be occasionally  the  subjects of
common  bubonoceles.
   The viscera, included in a congenital hernia, but more especially
the omentum,  are frequently adherent to the testicle; a complication
attended  with  serious inconvenience, unless removed, as it prohibits
the reduction of the protruded parts,  and the use of a truss.  The
bowel and omentum may also  adhere  to the sac,  and sometimes to
the sac and  testis at the  same time.
   A congenital inguinal  hernia is  to be treated on the same  general
principles which apply to other hernias.   If the bowels admit of re-
duction,  the patient be young, and a proper truss  constantly worn,
the communication between the abdomen and scrotum will frequent-
ly become obliterated, and a radical  cure be the result.  The chances
of this desirable event  diminish, however, as the individual grows
older,  and, after the adult age, a truss can hardly ever be safely dis-
pensed with.   Unfortunately, we  cannot always apply a truss, as
when a piece of intestine or omentum is in the sac, while the testi-
cle is in  the groin, or even within the abdomen; for, in the first case
it would  press upon and inflame the testicle, and, in the second,
prevent its descent.  However, if the patient should be  beyond the
age, when any chance of the descent of the testicle exists, I would
recommend the hernia to be reduced, and a truss applied.
   In young subjects, in whom  no congenital hernia exists,  but one
or both testicles have not yet passed the ring, their descent  should
be watched, and, as soon as they are low enough, a truss should be
worn, constructed so as not to make any hurtful  pressure on them.
   A congenital hernia is remarkable  for the  thinness of its sac; a 
HERNIA  OF THE  C02CUM AND
COLON.
209
fact dictating caution in the  first steps of the operation.   The sac
is,  indeed, frequently  not  thicker than the  natural peritoneum.
This hernia is also well known to be particularly often strangulated
at the inner opening  of the ring, or by a  contraction of the neck of
the sac within the inguinal canal.   It has also another peculiarity,
which is, that it  sometimes becomes strangulated by constrictions in
the body of the sac itself.
   As the epigastric  artery is always on the inner side of  the neck
of the sac, the division  of the  stricture may be safely  made up-
wards and outwards.
   Great  care should be taken not to handle, wound, or, in any man-
ner injure the testicle in the operation.
   A peculiar case is sometimes met with, consisting of a protrusion
of the viscera, together with  a  peritoneal hernial sac, into  the cavi-
ty of the tunica vaginalis.  It is formed after the recent obliteration
of the communication between the abdomen and the tunica vagina-
lis.  Were  we  not  aware of the possibility  of such  a case, we
might be considerably perplexed  on meeting with it.  In the mu-
seum of  University  College is  a preparation  of a double kind of
hernia: first, a congenital one, with  omentum in it; and, secondly,
another hernial sac pushed down into the tunica vaginalis.

             HERNIA OF THE CCECUM  AND COLON.

   Scrotal herniae of  the right side, formed  by the coecum, the  ap-
pendix vermiformis,  and commencement of  the colon, draw after
them into the scrotum that portion of the great bag or the peritone-
um by which those viscera are naturally  fixed in the right ileo-lum-
bar region; and, on opening the sac, we  find the ccecum and colon
connected to this part of the peritoneum, just as they were  in the
abdomen previously to the displacement.   The same kind of natural
adhesion  of the large intestines to the hernial sac may also take place
in a scrotal hernia of the  left side, when  the protrusion consists of
that part  of the colon which is naturally fixed in the left ileo-lumbar
region by duplicatures of the peritoneum.
  Another peculiarity of these herniae arises from  the ccecum and
beginning  of the colon being partly situated out of the peritoneum:
hence they  can only  be partially surrounded by a  hernial  sac, a
portion of their external side  being in. immediate contact  with the
adjacent  cellular tissue.   In such a case, were the surgeon to  cut
too much towards the outside of the tumor, he would find the coecum
and colon immediately under the cremaster and infundibular process
of the fascia transversalis.
  From what has been  stated, we discern the cause of another  pe-
culiarity of herniae of ihs coecum  and fixed portion of the colon,
namely, the impossibility of their reduction.   The appendix ver-
                            18* 
210
HERNIA.
miformis may be returned, but the ccecum itself cannot be reduced,
unless the sac itself admit of being replaced.
   These circumstances render it a matter of importance to discrim-
inate a hernia of the coecum and beginning of the colon from others.
Now, such a case can  only form gradually; the  displacement of
the coecum and  colon, fixed as they are  in their  natural situation,
must  be a slow process.   Herniae of sudden formation, therefore,
cannot be of this kind.   The tumor will  also generally  be of large
size, of long standing, and of an irregular knobby shape.
   In this species of  hernia, as  well  as in all others of large size,
the symptoms of strangulation are  seldom violent,  on  account of
the width of  the opening through which  the protrusion takes place.
We should in such cases  be cautious not  to mistake the colic irri-
tation, to which the viscera in the tumor  are  liable, for the  symp-
toms of strangulation.   When a large old  scrotal hernia is really
strangulated,  the evacuations from the bowels are soon  totally sup-
pressed, the  swelling is painful, and the  patient is affected  with
vomiting, eructations, and  fever.   On the contrary, in the colic
from  irritation,  resembling strangulation, the discharge of air and
feces from  the rectum is never entirely suppressed;  and the evacu-
ations are increased when mild  purgatives  and  clysters are  given.
If nausea and tendency to  vomiting occur, it  is at long intervals;
there is not much fever; and the swelling, though tense and bulky,
is not painful on being handled.   Under such circumstances, mild sa-
line purgatives, clysters, and cold applications,  may frequently be
employed with success, and we should not be in  haste  to perform
an operation.
   But, if a large hernia of the ccecum were to be truly strangulat-
ed, we should remember, that the  bowels  will  not admit of  being
completely returned, on account of  their particular  and  natural ad-
hesions to  the sac; and in this, as well  as  in all scrotal herniae of
large size, the neck of the hernial sac is not the  seat of strangula-
tion.   Here, perhaps, the best  plan would be merely to expose the
abdominal  ring, and make a division of  it, upwards and outwards,
without opening the hernial  sac  at all, and then to try to reduce the
viscera as far as practicable.

          THE  EXOMPHALOS,  OR  UMBILICALHERNIA,

Is a protrusion of the viscera through the naval, or in the neighbor-
ing part of the linea alba.   The first case, whether met with in the
infant or adult, has a circular  neck,  at the circumference of which
the tendinous margin of the umbilical ring can  be felt.   Whatever
may be the  size of the tumor, its  body always retains nearly a
spherical shape;  nor can any  wrinkle of the skin, nor  any thing at
all resembling the cicatrix of the naval, be seen upon the convexity 
HERNIA IN THE LIN^E  ALBA.              211
or the sides of the swelling.  On the  contrary, in a hernia of the
linea alba,  the neck of the swelling  is  of an oval shape, like the fis-
sure through which the protrusion  has  taken place; and, if the her-
nia be very near  the naval, the  umbilical  cicatrix may be seen on
one of the sides of the swelling—a  sure proof that the  viscera  do
not protrude through the umbilicus itself.
   In a true exomphalos, the tumor in a thin person is free and pen-
dulous;  in  a fat  subject, round at its base,  less  prominent,  and
hence spherical.   The  protruded  parts will  naturally tend down-
wards, so that the opening into the abdomen is from the upper part
and not from the middle of the swelling.
   The umbilical hernia is not only furnished with  a true peritoneal
sac, but with  a superficial  investment  of  condensed cellular sub-
stance.   The coverings  of this hernia,  however,  are frequently
very thin, and, in old cases, portions of the sac are sometimes ab-
sorbed.   Nay, the viscera may be adherent to the  integuments, and
strangulated by the opening in  the  sac,  through  which they  have
protruded,  and which has  been occasioned  by its partial absorp-
tion.
   An umbilical rupture in an adult  rarely contains intestine unac-
companied  by omentum.   The disease happens with much greater
frequency in women  than men; a fact explicable by the considera-
tion that pregnancy has more  influence  than any other cause in
bringing on the complaint.   Dropsical  and  corpulent subjects, how-
ever, of both sexes  are particularly liable to it.

    HERNIA IN  THE  LINEA ALBA   OR  VENTRAL  HERNIAE,

Are much slower in their progress than a true exomphalos.   On ac-
count of their small size, they are frequently unobserved, especially
in corpulent subjects, or when situated on  one side of the ensiform
cartilage.   However, they bring on complaints of the stomach and
habitual colics, and are more liable to simple obstruction, than  stran-
gulation with  inflammation and  tendency to  gangrene.   But when
this state unfortunately does occur, the symptoms are  more intense,
and the accession of mortification  more rapid, than  in  any other
species of  hernia.  Even when merely the omentum is strangulated,
the symptoms are particularly violent, a circumstance ascribed to the
proximity of the stomach.
   When practicable, the exomphalos and ventral hernia? should  be
reduced, and a truss worn.   In Hey's Surgery is a description of an
excellent truss for umbilical hernia.   In young subjects, the pressure
of a truss will  often radically cure the disease; and the plan is much
more  commendable,  than that  of reducing  the viscera, and  then
extirpating the  integuments and sac with a ligature.
   When,  in adult subjects, an operation  is  unavoidable, the  sac 
212
HERNIA.
should be  laid open with the greatest  caution, and  the umbilical
ring divided  either  directly  upwards  or downwards.  When the
hernia is very large, but not attended with gangrene,  we should be
content with  cutting the umbilicus, without opening the sac at all,
or as little of it as possible.
   The division of the stricture in ventral hernia may also be made
upwards  or downwards, due regard  being paid to the epigastric ar-
tery which crosses the linea semilunaris.

         CYSTOCELE,  OR  HERNIA OF  THE BLADDER.

   The protrusion  is most frequently through the abdominal ring;
and  generally in male subjects who have  been repeatedly afflicted
with retention of urine.  Cystocele has been noticed, however, in
children, from the irritation of stone, and  even in women from the
effects of dropsy and pregnancy.
   Only the fundus and a part of the posterior surface of the blad-
der, down to the insertions of the ureters, are covered by peritoneum.
Now, as it is usually the  anterior and lateral  part of the bladder
which  first passes through  the  ring into the scrotum, the  perito-
neum will not protrude at the same time, and the displaced part of
the bladder will not  be covered by a hernial sac; but, as more of
it  descends, its fundus at length passes  into  the  scrotum, drawing
after it the peritoneum naturally attached to  it.   Thus the bladder
first protrudes, and a hernial sac follows, into which a portion of the
omentum or intestine may  glide.   Here the bladder  is invariably
excluded from the other hernia, and situated at its posterior and in-
ner side.  Sometimes the case is  reversed, and the  cystocele is
the consequence of an ordinary  hernia.
   The symptoms of cystocele are  a  fluctuation  in  the tumor, the
sweHing  becomes large and tense  when the  patient holds his wa-
ter, and  diminishes when the urine  is discharged.   If the scrotum
be compressed, an inclination to make water is  experienced.   Some-
times,  the muscular coat of the bladder being paralytic, the patient
cannot expel  the urine from  the swelling, unless he raise and com-
press the scrotum; indeed, as the  bladder  is always drawn to one
side, the patient  invariably  has more or less difficulty in making
water, and is sometimes afflicted with a  total retention.
   The disease has been mistaken  for hydrocele,  though the  marks
of difference are great.   Thus, the tumor produced by the bladder
always extends into  the ring, the testicle is  plainly perceptible be-
low the swelling, and the tumor  diminishes when  the patient  voids
his urine.
   Cystocele may occur also under the crural arch, in the perinaeum,
or the vagina.
   The reduction of  a cystocele is  soon rendered  totally impossible
by adhesions;  and all that  can be  done is to apply a suspensory 
ACUTE  INFLAMMATION  OF THE TESTICLE.        213
bandage.   If a total retention of urine were to attend it, caused by
the displaced condition of the organ, and not to admit of a catheter
being passed, the swelling should be punctured.   If a calculus were
to form in the protruded  bladder, an incision might be practised for
its extraction.
   This is all the information which  I can offer  on  the  subject  of
hernia in this treatise.   Some  forms of the disease, like herniae at
the foramen ovale, or ischiatic notch, in the vagina,  or perinaeum,
or through the diaphragm, are rare;  though I would  advise all sur-
geons to remember them, and be prepared for  them.  They will
be still more likely, I think, to meet  with cases, in  which the bow-
els within the abdomen become strangulated by  accidental displace-
ments, bands of adhesion, or various other causes.
   [A new mode of treatment,  for the radical  cure of hernia, has been
introduced within the last three years  in  this country,  ft  is still  a
matter of dispute, as to whom  the credit of its introduction  belongs.
the operation consists in making an opening in the integuments, and
then in introducing, by means of a small syringe, some stimulating fluid,
like the oil  of  cloves, upon  the neck of the sac, near  the ring or
opening in the abdominal wall.  This excites inflammation, which is
designed to produce adhesion between the walls of the sac and  at its
neck.  The patient must be watched  for a few days;  and if  the  ex-
citement be loo great, it must be moderated by the appropriate mems ;
if it be not sufficient,  it may be increased  by repeating the operation,
or by the firm application of a truss, so  as to effect  the  desired oc-
clusion.
   My experience in this  mode of treatment has beer.  lb»:i«ed. yet I
have seen  enough of it  to  form rather a favorable opinion of it, and
to regard  it rather as a methed of management which deserves trial.
—Ed.]
      DISEASES  OF  THE GENITAL ORGANS.

   The  testicle  is  particularly  often the seat  of inflammation and
disease, owing, perhaps, to circumstances adverted to by  Sir Astley
Cooper, namely, the  slow manner in which the blood  returns from
it against  its own gravity; the occasional immoderate distension of
the seminiferous tubes; its exposure to injury  from blows  or pres-
sure; its sympathy  with morbid  conditions of the urethra and pros-
tate gland; and the changes, which it almost naturally undergoes in
old subjects.
   The classification of the diseases of the testicle, adopted by this
able pathologist, is, first,  into those which are the result  of common
inflammation, acute or chronic;  secondly, into those which  are of 
214          DISEASES  OF THE  GENITAL ORGANS.
a specific nature, but not malignant;  and thirdly, others, which are
both specific and malignant.
   The first division comprises acute and chronic inflammation, and
atrophy of the testicle.   The  second, embracing diseases, attended
 with specific, but  not malignant action, comprehends  what  Sir
Astley Cooper names the hydatid or encysted disease of the testicle;
the irritable testicle, or neuralgia testis; the  swelling of this organ
frequently occurring in the  disorder of the system  termed  mumps;
ossific changes in the part;  solid tumors of the epidydimis,  or the
testis; scrofulous testicle; and  what has been occasionally  denomi-
nated the venereal  sarcocele.   The third division of the classifica-
tion, including specific and malignant affections, comprises  medul-
lary cancer,  or fungus hematodes,  and scirrhus.   But,  besides
the numerous varieties of disease now referred to, there are several
diseases of the coats of the testicle and spermatic  cord, for which
the advice of a  surgeon is  often requested.   Now,  if  attention be
not paid to the subject, the  ignorant practitioner will be likely to get
into serious scrapes, by confounding one disease with another; mis-
taking diseases of the  body of the testicle either for hernial  swell-
ings or hydroceles; or these  again for  enlargements of the testicle
itself; and  varicous swellings  of the spermatic veins for herniae or
herniae for varicoceles.   I am continually meeting with patients who
either have herniae,  and, not being aware of the nature of their cases,
do not wear trusses, or who are wearing trusses on the supposition
of their having herniae,  when, in truth, they have no such complaint.

          ACUTE INFLAMMATION OF  THE  TESTICLE,

When it arises from gonorrhoea, or some other kind of irritation in
the urethra, is frequently,  though absurdly,  termed hernia humor-
alis.  It is often excited by strictures, and still more commonly by
the means ordinarily employed for  their cure, namely,  bougies, the
irritation of which becomes  the cause  of the affection  of the  testicle.
When inflammation of the latter organ is thus excited by disease in
the urethra, it is preceded by soreness or irritation  about the  mem-
branous and prostatic portions of that canal; the spermatic, cord be-
comes swollen and tender; and in particular the vas deferens, which
seems much thickened, and  on being touched,  is extremely painful.
When the case is still further  advanced, the swelling  extends to the
whole of the  testicle, the hardest part  of it being the  epidydimis.
In general, so considerable is  the enlargement of the  organ  in every
severe case, that the scrotum is exceedingly distended,  and  its rugae
being effaced, its surface is  completely smooth.  Painful as the in-
flamed testicle is  itself, a still greater  degree of suffering  is often
experienced in the  lumbar and inguinal  regions, with great uneasi-
ness about the hip and  thigh.   Sometimes the  agony in the part af-
fected seems to  have paroxysms  of increased  severity, which are 
           ACUTE INFLAMMATION OF  THE  TESTICLE.      215

alleged to depend upon spasmodic  contractions of the fibres of the
cremaster.  The scrotum, besides losing  its naturally  corrugated
appearance, is also reddened.   These symptoms are accompanied
by an acceleration of the pulse, constipation, restlessness,  thirst, heat,
and dryness of the skin, and other symptoms of inflammatory fever.
The blood taken away from the patient is also  found to be bufty.
Sometimes the stomach is disordered sympathetically, and nausea,
and even repeated vomiting  may occur.   I once attended a man for
an acute inflammation of the testicle, who labored under  so obstinate
a suppression of the stools,  and such a repetition of vomiting, that
a suspicion of strangulated hernia was created for a short time, but
quickly abandoned on a  careful examination  of the swelling.   In
fact, a general enlargement of the  testicle,  like that from acute in-
flammation of the organ, is  not at  all  likely to be mistaken for any
kind of hernia, excepting  the congenital; because in  bubonocele
the testis may always be felt at some point or another below the
hernial tumor.
   Inflammation of the testicle may be the  consequence of external
violence; and it  is often  purposely  produced by  various  surgical
proceedings, employed  for  the radical cure of hydrocele.   Some-
 times  it is brought on by the pressure of badly constructed trusses;
sometimes as one of  the effects of the disorder of the system, well
known by the appellation  of mumps.
   When the testicle  inflames and  swells in gonorrhoea,  the  pain in
making water and the discharge of matter are almost  always sud-
denly diminished, or  even suspended; a  circumstance ascribed  by
some  pathologists to metastasis;  and by others to sympathy be-
tween  the urethra and the testicle.  All that I can say upon  this
 point is, that we seem to know little more than the fact itself, which
 is exemplified, I think, with remarkable frequency in patients,  who,
 while  they have a  clap,  take rough exercise, indulge  in wine, and
 live altogether too freely.   One thing here merits attention, and  it
 is perhaps what would not have been expected, namely,  the swel-
 ling of the  testicle does not always come  on exactly at the period
 when the inflammation in  the urethra  is worst, but  frequently when
 it is on the decline, or even nearly cured.   Occasionally, also, the
 inflammation  of  the  testicle is  not followed by any diminution or
 stoppage of the discharge;  a fact  clearly overturning the doctrine
 of metastasis.   A suspicion is entertained, that the inflammation is
 sometimes propagated to the testicle  from the mouth of the vas de-
 ferens.   Mr. Hunter did not,  however, adopt  this view, because
 he found a swelling of the testicle to be as frequent in gonorrhoea,
 where  the inflammation did  not extend  further than an inch or so
 from the orifice of the urethra, as where it reached to the neck of
 the  bladder.   Another idea is,  that a swelling of the testicle is par-
 ticularly disposed to  come on when gonorrhoea is suddenly checked
 by the employment  of copaiba,  cubebs,  or  astringent injectionsj 
216         DISEASES  OF THE GENITAL ORGANS.

but, the correctness of this opinion may be doubted; for, many ex-
perienced surgeons believe, that they have seen an  inflammation of
the testicle arise as  frequently under other modes of treatment as
that now alluded to.   At the same time, I feel it right  to mention,
that Sir Astley Cooper inclines to the belief,  that  injections really
have a tendency to bring on hernia  humoralis, especially when they
are made to pass far into the urethra.   Notwithstanding Mr. Hun-
ter's view, I am disposed  to think, that  inflammation may some-
times extend to the testicle from the urethra,  by the course of the
vas deferens;  and Sir Astley Cooper describes certain appearan-
ces, noticed in the dissection of the urethra of a criminal, who had
been  executed, which confirm  the possibility of this  occurrence.
The man had a gonorrhoea at the time of his  death;  and when his
urethra was cut open, although the  inflammation was greatest in the
first three inches of  the  canal,  yet it extended also to the mem-
branous portion of it, and even  blood had  been extravasated under
the mucous membrane.   Under such circumstances,  the verumon-
tanum, and the terminations of the common  ducts  of the  vesiculae
seminales and vasa deferentia in the urethra, participate in the in-
flammation, which may then be propagated along  the vas deferens
to the cord, epidydimis, and testicle.
   One fact,  relative to  this subject, is certain; which is,  that in -
flammation of the testicle rarely or never comes on in the early stage
of gonorrhoea, but usually between the tenth  day and the end of the
third  week.   When the pain and swelling begin to abate,  the dis-
charge from the urethra  very commonly returns.  Within the tunica
vaginalis there is generally a quantity of serum effused, vyhich, after
the inflammation  has subsided, is  absorbed again.   We find like-
wise that fibrine is thrown out within the   same membrane, and  in
the interstices of  the glandular  part of the testicle,  occasioning con-
siderable hardness, the remains of  which  will  often continue a long
time.
   The treatment of acute inflammation of the testicle must, of course,
be antiphlogistic, comprehending  quietude,  and   even the hori-
zontal posture in bed, if the case be severe.   When the patient is
young and robust, the swelling considerable, and the pain in the lum-
bar region violent, we should have recourse to venesection, and this
pretty freely; and in all  cases,  leeches, saline purgatives,  and low
diet,  are absolutely necessary.   If leeches cannot  be procured, the
veins of the scrotum may be  punctured,  whereby a  copious and
beneficial discharge of blood may generally be obtained.   With  re-
spect to local applications, we may employ cold evaporating lotions;
or, if the patient seem to derive great relief from emollient  poultices
and  fomentations, these may  be  used.   Perhaps,  in very severe
cases, the latter ought always to  be preferred.   But, nothing will
lessen the  patient's sufferings more effectually, than the plan of tak-
ing off the weight of the  testicle  from the spermatic -cord with a 
ATROPHY OF  THE TESTICLE.
217
bag-truss or suspensory bandage;  it has, indeed, the greatest effect
in diminishing the pain experienced in the back and inguinal region,
particularly when assisted  by bleeding, saline purgative medicines,
and the occasional exhibition of eight or ten grains of the compound
powder of ipecacuanha.   When the disease has arisen from the ir-
ritation of bougies, their employment must, of course, be suspended.
One  plan  that has sometimes proved expeditious in stopping the
inflammation, and bringing down the swelling, is that of prescrib-
ing tartarised antimony, so as to keep up  a degree of the nausea;
but  the  practice is not commonly  adopted,  because patients more
readily submit to other meads of relief.
   In general, a considerable hardness of the  testicle, and especially
of the epidydimis, remains  after  the inflammation has been com-
pletely removed: sometimes during the rest of the patient's  life.
Mr. Hunter even suspected  that, in some cases of this  description,
the canal of the epidydimis was impervious,and the  function  of the
testicle annihilated.  However, this suspicion does not coincide with
the examinations instituted by Sir Astley  Cooper, who says, that,
when the swelling is at the lower part of the epidydimis, it is  seated
in the cellular tissue of the vas deferens, where it forms its first con-
volutions, and is  not an  effusion within the cavity  of the  duct.
The induration, according to his researches, frequently affects mere-
ly the tunics;  and when situated in the upper part of the globus ma-
jor,  it arises either from fibrine effused  in  the  cellular substance
between  the coni  vasculosi,  or else from a sac filled with a  viscid
fluid.
   For promoting the dispersion of the chronic induration, remain-
ing after  all acute  inflammation is over, we may employ  camphorat-
ed mercurial ointment, with or without two scruples or a drachm of
the hydriodate of potash in  each ounce of it.  Or we may  try
poultices of vinegar and oatmeal, or the  hydrochlorate of ammonia
lotion, where friction cannot  be borne.  In some cases, good  seems
to be produced  by internal alterative medicines,  as  the compound
calomel pill, and sarsaparilla, or the tincture of iodine.
   Acute inflammation of the  testicle, when a consequence of gonorr-
hoea,  or irritation in the  urethra,  rarely suppurates; but  when pro-
duced by external violence,  the chance of an abscess is greater,

                 ATROPHY  OF THE  TESTICLE,

Or a more  or less complete wasting  away or absorption of this or-
gan, may follow the subsidence of acute inflammation of it;  but it
more frequently takes place when such inflammation has been brought
on by external violence, than when it originates as a consequence of
gonorrhoea.   No doubt, under these circumstances, the structure of
the testicle has been irreparably damaged by the inflammatory pro-
cess; and probably in some instances, the atrophy may depend  up-
  VOL. II.                   19 
218          DISEASES  OF THE  GENITAL ORGANS.

on an obliteration of the vas deferens; for, in the  museum of  St.
Thomas's  Hospital,  there used  to be a testicle in this condition,
the vas deferens of which could only be filled with quicksilver.for
about half an  inch of its extent  from the abdominal  ring towards
the testicle itself.   This fact is  reported  in  Sir Astley  Cooper's
work.   An atrophy of the  testicle sometimes takes place without
any previous  inflammation of it: the pressure of a truss on the sper-
matic cord will produce it; and  many curious cases are recorded
by Larrey, where sabre wounds about  the occiput and nape of the
neck were followed by  it.

  CHRONIC ENLARGEMENT,  OR  CHRONIC  INFLAMMATION  OF
                        THE TESTICLE,

Usually commences with hardness and swelling of the epidydimis,
at first attended with  but moderate uneasiness, scarcely amounting
to pain; at length the glandular part of the  organ becomes involved,
and the testicle seems rather larger and more tender than that of the
other side.   If the disease arise  from a blow, then it may begin in
the body of  the testicle, which may  present  a globular, instead of
its naturally oval form, and sometimes, though enlarged and altered
in shape, it has no inequalities upon its surface.  In other instances,
however,  it  is at first  unequal,  so that knobs can  be felt upon it;
and this, according to Sir Benjamin Brodie, is usually  the  case in
the beginning; a general uniform enlargement, without any knobs,
being the more advanced state of the disease.
  The case is rarely  so painful as to compel the  patient  to keep
himself quiet, and refrain altogeiher  from  labor and exercise.   In
some cases, a clear transparent serum is effused in the tunica vagi-
nalis, constituting  one of the  forms of disease, to which  the term
hydro sarocele is vaguely applied.   In ordinary cases, the spermat-
ic cord is not hardened, but its veins are  somewhat enlarged;  and
when  the disease  has existed some considerable time, and has at-
tained  magnitude, the  patient complains of pain and a sense of weight
in the loins and thigh.
  This chronic inflammation of the testicle, the sarcocele tuberculeux
of Cruveilhier, which has been  well  described  by Sir Benjamin
Brodie, leads to the production of a yellow tubercular substance in
the texture of that organ; an unorganised  yellow  matter, collected
at first in small masses,  but afterwards in larger ones at certain parts
of the testicle;  while, in other  places, the glandular  structure is
quite healthy.  In a later stage, the yellow matter, which is secret-
ed within the tubuli testis and  epidydimis, assumes a harder consis-
tence,  and  is generally laminated.   This disease  is met with in va-
rious  unhealthy states of the constitution, whether connected with
rheumatism,  syphilis, or other causes.  It  often presents  itself in
persons who have been  scrofulous in their youth, or whose constitu- 
FUNGUS
GROWTHS  FROM THE TESTICLE.
219
tions have been broken by the long use of mercury.   What has been
termed  the venereal sarcocele is only a variety of it.   In this latter
case, according to Cruveilhier, the tubercular deposit  always takes
place first in the epidydimis.   He describes one remarkable instance,
in which the tubercular substance  was deposited not only  in the
epidydimis and body of the testicle, but in the vas  deferens, the
vesiculae seminales, seminal ducts, and the prostate gland*.
  According to Sir Astley Cooper, when a solid effusion has taken
place ih the seminiferous tubes, or even in the substance of the tes-
ticle, or epidydimis, the disease may be cured by the strict  obser-
vance of the recumbent posture, and the exhibition of three grains
of calomel and one of opium, night and morning, so as to keep the
gums affected for a month at least.  A  black  dose and fifteen  or
twenty  minims of the liquor antim. tart, are to be given every fourth
morning.   The topical treatment should  consist  of  leeches twice a
week, and a lotion composed of the liq. ammon. acet.  §v.  and one
ounce of spirit of wine.  Cruveilhier supports  the  same view, ob-
serving  that a deposit of tubercular matter in the epidydimis,  or even
the body of the testicle, is  not an adequate reason for castration.

GRANULAR PROTRUSIONS,  OR  FUNGOUS GROWTHS FROM  THE
                           TESTICLE,

May follow the formation and bursting of an abscess in the part;  or
they may occur in the advanced stages of chronic  inflammation of
it.   At one point, the  testicle  adheres  to the  skin, inflames, and
ulcerates;  and  then, through the  ulcerated opening, a fungus  of
  mall size at  first projects, but, gradually acquiring  greater bulk,
makes  its way through  openings, not only in the tunica vaginalis,
but in all the investments of the scrotum.   Now, according to Sir
Benjamin Brodie's  investigations,  we may trace on the  surface of
this fungus the same kind of  yellow matter, found  in  the  glandular
portion of the testicle,  which  glandular texture  itself likewise pro-
trudes,  until no  part  of the testicle is left within the scrotum, and
the spermatic cord  can  be  distinctly traced into the centre of the
fungus.   In a still more wasted condition of the glandular structure,
the cord terminates in a small tubercular mass, the only remains of
the organ.  The height to which the fungous or granular  protru-
sion rises, prevents the skin from healing over it; but it may gene-
rally be reduced by the  pressure of a dossil of lint, fixed on it with
adhesive plaster, or it may be got rid  of with  escharotic applica-
tions.   However, the surest  mode of cure is that  of cutting away
the protruding mass on a level with the inner reflexion of the tunica
vaginalis, making two semicircular incisions, and afterwards bringing
* Cruveilhier Anat. Pathol. liv. ix. p. 2. 
220         DISEASES  OF THE GENITAL ORGANS.

their edges together.   The plan is not, however, approved of by
Sir Benjamin Brodie, because  in doing it we actually slice  away
the tubuli testis; and  hence, he prefers sprinkling the fungus  with
red precipitate, and giving mercury.   Then, as  soon as  healthy
granulations form, he dresses the sore with  a solution of the sulphate
of copper in camphor mixture.  I  believe  it  to be a  very good
practice, when abscesses of the testicle  leave deep and fistulous
openings, to prescribe calomel and opium in the manner directed by
Sir Astley Cooper, and  to inject into  the fistulae a  lotion of the
sulphate of copper, or bichloride of mercury.
      THE IRRITABLE  TESTICLE, OR NEURALGIA  TESTIS,

Is a case analogous to tic douloureux, or neuralgia in other parts.
It is a highly sensitive and painful state of the organ, often without
any very obvious cause, the suffering  produced by it being frequent-
ly of the  most excruciating kind, and of long duration, though sub-
ject  to occasional  remissions.   The part is but little,  if at  all,
swollen; and, on dissection, no change of structure can be  detected.
One  example, however, of this  affection in  a medical  student, in
which I was lately consulted,  and in  which Sir Astley Cooper was
also  kind  enough to give his advice, had been attended with repeat-
ed swelling of the testis, though  it mostly remained  with scarcely
any perceptible  change  of size.   The most successful treatment
consists in giving large doses of the sulphate of quinine or carbonate
of iron;   or, when  the  disease  assumes  an  intermittent  type, the
liquor arsenicalis.   Opium, the acetate or hydrochlorate of morphia,
the extract  of conium, hyosciamus, and other narcotics, with calo-
mel, may also be given.   If the  secretions of the skin and liver be
defective, calomel, opium, and antimony may be tried in  combina-
tion.
  As local applications,! may recommend leeches, ice,  or a plaster
composed of one third of the extract of belladonna and two thirds
of soup cerate.   This is a disease, in which the ointment of vera-
tria may  deserve trial.  In one instance, Professor Gibson dissect-
ed down  to the spermatic nerves, and  divided  them; a difficult
operation, but alleged to have answered.*
  No doubt, neuralgia testis frequently depends upon some disorder
of the system at large, the removal of which is an essential thing in
the cure.   That severe  pain  in the testicle may arise from sympa-
thy between this organ and other parts, without any alteration of its
structure, is illustrated in cases, where great  agony  in the testis is
experienced on the descent of a calculus  from the kidney into the
  * Gibson's Institutes, &c. of Surgery, vol. ii. p. 179., ed. 5.  Philadelphia, 8 vo.
1338. 
CYSTIC  SARCOMA.
221
ureter.   In particular  instances, however, a degree of swelling of
the part, a varicose fulness of the  spermatic  veins, or even some
hardness or prominence about the epidydimis, may be  observed.

               OF THE SCROFULOUS  TESTICLE.

   The secreting  glands are rarely  affected with scrofula; but  this
organ forms an exception.  Even in young children, it  may become
enlarged and  hardened, without pain,  and  remain  in  this indo-
lent state for  many weeks,  months, or  years; and  then,  as  the
health improves,  gets well.   More frequently, the disease  occurs
towards puberty, preceded or accompanied by some other marks of
scrofula, and sometimes it  affects  both testicles.   Scrofulous  dis-
ease of the testicle is remarkable for its indolent character, and the
little pain attending it;  we perceive a trivial swelling of some  part
of the organ,  mostly the epidydimis; and, afterwards a small super-
ficial  lump at  another point.   These little tumors  increase, and by
degrees create greater  uneasiness in the part.   The skin becomes
adherent to them;  they suppurate;  the abscesses burst, but discharge
only a scanty quantity of matter; and the openings, having little  ten-
dency to heal, remain  fistulous.  At length, the  testis  sometimes
diminishes and wastes  away,  until but a small portion  of it is left;
but, more commonly, the organ is not wholly destroyed, and a con-
siderable part of the glandular structure remains.
   The treatment is to be conducted on the same  principles as are
applicable to other forms of scrofulous disease.   We may prescribe
rhubarb and carbonate of soda in equal proportions (ten grains of
each) to be taken once or twice a day; liquor potassae;  preparations
of iodine, or tonics of various  kinds, according to the circumstan-
ces of the case, and the effects which are produced by such means
on the part and the whole system.   With respect  to iodine, I pre-
fer the way in which it is prescribed by Lugol, to the  less diversi-
fied mode in which we employ it.

   CYSTIC SARCOMA--HYDATID  DISEASE  OF THE TESTICLE.

   This latter term is objected to, as conveying the erroneous notion,
that hydatids exist in the part.  The morbid  mass, into which the
organ is converted, is partly composed of a solid structure, and part-
ly of cysts, varying in size from that of  a large pin's  head to  that
of a small marble; some of them containing a thin, transparent,  yel-
low serum, and others a more turbid fluid.  The disease  occurs chief-
ly between the ages of thirty and thirty-five, and is sometimes mistak-
en for hydrocele;  though the shape of the tumor ought  to serve  as a
criterion, since  it is oval, not pyriform, like  that occasioned by a
collection of fluid in the tunioa vaginalis.  The particular character,
however, of enlargement of the testicle with cysts cannot always be
                            19* 
222          DISEASES OF THE GENITAL  ORGANS.
known with certainty previously to the examination of the part after
its removal by operation.   It is not malignant, for it  never extends
to other parts: it may however be conjoined with medullary cancer,
which is itself malignant.  No treatment is of any use, because the
disease is truly an organic one,  accompanied  by a total disorganisa-
tion of the testicle, and changes of structure, leaving no possibility
of a return of the part to  its  healthy state again.  The pain, caused
by the weight of  the tumor  on  the  spermatic cord, and the annoy-
ance of its bulk, frequently  compel the  patient to submit to cas-
tration.
  What we call cystic sarcoma of the  testicle, is termed by  Cru-
veilhier, Cancer Alveolaire, of  which he has given an excellent rep-
resentation in pi.  1. liv. 5. of his Anatomie Pathologique.  In the
dissection of the  specimen from which  the engraving  was taken, he
ascertained, that the proper substance of the testicle did not partici-
pate in the morbid change, but  was pressed  by the new  formation
towards the surface of the tumor, where it formed a thinnish stratum
of a grey  semi-transparent appearance.   " The further/' says he,
u we advance in the study of morbid alterations, the more we shall
be convinced of  the truth  (which, I believe, was first announced by
me,) that our textures are unalterable, and that what are called mor-
bid lesions, are new productions, endued with an independent life of
their own,  and that our tissues are only susceptible  of hypertrophy
and atrophy. Here the atrophy is admirably explained by the com-
pression which the substance of the testicle bad undergone."

            MEDULLARY  CANCER OF  THE TESTICLE

Is a  malignant  disease, that has received a variety  of names;  by
some it is called the pulpy testicle; by some it  is denominated med-
ullary sarcoma;   by others fungus hemaiodes; a term that is only
warranted in an advanced  stage of the  disease, when a mass, which,
from its look, is mistaken  for a  fungus,  occasionally, though not of-
ten,  protrudes through  the  scrotum.    It is  the soft cancer of the
testicle, as it is denominated  by some writers, on account of its ma-
lignancy; that is to say, its having a tendency to extend itself in the
course of the absorbents; its disposition to attack other textures;
its incurable nature; its  general character  to show itself again in the
same, or other parts, after removal by  operation; and its connection
with some  undefined,  but  highly unfavorable condition of the system.
By Cruveilhier it is named sarcoclle areolaire encephaloide.   The
disease begins in the body of  the testicle, which  it enlarges, the
swelling  extending  to  the whole of this  part of the organ in the
course of three  or  four months.  Afterwards the  epidydimis be-
comes involved.  While  confined to the  body of the testicle, the
swelling is  of an oval figure;  one circumstance, by which  the case
may be known not to be a hydrocele: but as soon as the epidydimis 
MEDULLARY CANCER  OF THE  TESTICLE.        223
is diseased, the tumor may  assume  a somewhat  pyramidal shape,
and be not unlikely to be mistaken for a hydrocele, more especially
as the disease is attended with a softness and elasticity, which often
lead the practitioner to think, that he feels a fluctuation in the part.
Indeed, there is sometimes a small quantity of fluid in the  tunica
vaginalis.   I should say, however, that,  with due attention, a med-
ullary tumor of the testicle  may almost always  be descriminated
from hydrocele, by the tumor presenting a more decidedly oval form
than the latter disease; by its greater weight;  its  having no trans-
parency; its being harder in some parts than others; its not  being,
after a  time, so uniformly smooth as a hydrocele;  and its being ac-
companied by a sallow, unhealthy look, such as is usually indicative
of a malignant organic disease of an important part.  At first, the
swelling is not attended with  pain; but, after a little while, the pa-
tient begins to experience shooting, darting sensations from the tes-
ticle,  up  the  spermatic cord to the  lumbar  region and the  groin;
and the part will not bear much handling, without  a great  deal of
tenderness being produced in it.  The period of life in which med-
ullary sarcoma of  the testicle is most frequent, is that between pu-
berty and the  age of 35 or 36;  but  Mr.  Earle has recorded a rare
instance of its occurrence in a  very  young child.   These  circum-
stances deserve attention; because, though medullary disease of the
testicle is seldom met with  in children, the same  disease of the eye
is chiefly confined to them.                                /
   The swelling consists of a mass  of medullary very  albuminous
matter, or of  a  pulpy  substance,  firmer than the medullary matter
of the  brain, included in the interstices of a thin, delicate,  transpa-
rent membranous texture.   It would not be correct to say, that the
organ is always converted into this kind of substance; for,  in many
cases,  the medullary substance is not a molecular deposit, after the
manner of nutrition, but an  adventitious formation, an additional
growth, which by its pressure seems to  cause  the removal  of the
original tissues.   Sometimes the glandular portion of the testicle
remains unaltered, while.a medullary tumor lies beneath  the tunica
albuginea, or grows from the superficial part of the testicle, and fills
the cavity of the tunica vaginalis, of which Sir Benjamin Brodie
relates one instance, and Cruveilhier another.   At last, however,
the substance  of the testicle always  suffers atrophy from the  com-
pression of the new and extraneous  substance, whether this be first
formed within the testicle, or on its surface.
  In the latter stage of the disease,  the tumor becomes adherent to
the scrotum;  the  spermatic  cord becomes knotty and unequal; at
length  ulceration of the scrotum may take place, and a large mass
of the  medullary substance  protrude, from which copious  hemor-
rhage every now and then occurs.   The protrusion of such a mass,
however, I believe, is much less frequent in medullary disease of the
testicle than  in the same disease of the breast, eye,  and  limbs. 
224         DISEASES  OF THE GENITAL ORGANS.

Sometimes, when the scrotum is implicated, the inguinal glands be-
come affected;  but it is the lumbar, which are so liable to be involv-
ed in the disease.
  This malignant disease of the testicle has a tendency to  extend
itself in the course of  the absorbents, and to attack many different
parts and tissues in the same person.  As the absorbents of the tes-
ticle  pass  to the lumbar glands, these are frequently involved, and
sometimes are transformed into an immense mass, equal  in size to a
child's head, readily  perceptible when the abdominal muscles are re-
laxed, and causing, by their pressure on neighboring organs, various
functional disturbance.   Such may  be the case,  even when the
spermatic cord itself is sound.   Too frequently, indeed,  the testicle
is only one of numerous parts which are implicated; and soon after
this organ has been  removed, the patient may die, and on his being
opened, we may trace various other medullary tumors in the organs
or  membranes  of the  cranium,  chest, or abdomen.   Cruveilhier
gives the particulars of one case, in which the ascending vena cava was
filled with  medullary  matter.  In  another, in University College
Hospital, after  I had  removed  the  testicle, the  medullary  growth
of one  of  the  lumbar  glands made  its way  into the pelvis of the
kidney.  Even  the beginning of the thoracic  duct has been oblite-
rated by the pressure of the diseased mass.   Some  surgeons of
great experience, who have removed many testicles, affected with
medullary  cancer,  have not known  one  instance of a permanent
cure being  effected  by such operations.   This  fact, at all events,
is a lesson  to us in delivering a  prognosis; we should candidly ex-
plain the chances of a return of the  disease, and  let it not be said,
that we have persuaded the patient  to submit to the operation as a
certain means of cure.   In the museum of University College is a
fine specimen of a medullary  cancer  of the testicle, one  of conside-
rable size,  which I removed  from  a young man about  thirty years
of age, who had a remarkably  sallow unhealthy look.   The case
illustrates several  interesting  circumstances.   The  patient  came
from  Oxford, where a surgeon  had  introduced  a trocar into the
swelling, on the supposition, no doubt, that the case might be a hy-
drocele.  Another  practitioner had been  led to do the  same thing.
The punctures,  however, healed up very  well, without  any subse-
quent  inflammation, or any  protrusion of the  morbid  substance;
a circumstance, which  I had an opportunity of noticing; for, not
being aware of these fruitless operations, and fancying one morning
that a fluctuation was perceptible,  I also passed  in a tocar, but no
material harm resulted from the experiment, only a very slight de-
gree of pain, the wound healing up completely in two or three days.
I showed the case to Sir Astley Cooper, who advised  castration,
which I performed, and then sent  the diseased testicle  to him,
which he injected and  carefully dissected.  One section of it, with
the spermatic vessels,  he retains himself;  the other  he was  so ob- 
MEDULLARY CANCER  OF
THE TESTICLE.
225
 liging as to send to me as a present.   In  the examination of the
 cord, minute extraneous substances, some of  them less than pins'
 heads, were noticed in  the cellular tissue, which were  suspected by
 Sir Astley Cooper to  be  of a medullary  character.   This was a
 very discouraging circumstance,  one that fully prepared  me to ex-
 pect a return of the disease; yet contrary to my  expectation, the
 wound, caused  by the operation,  healed  up favorably,  the man's
 health improved, and he continued well more than  three years from
 the period  when  the  testicle was  removed.  We learn  from  this
 case, that  the  introduction of a  trocar into the swelling  is not at-
 tended with any serious consequences;  and that even when the pa-
 tient has a  very unhealthy, sallow look, and the cord is not entirely
 sound, there  may not  be  a return of the disease.   We  must not,
 however, anticipate  success as a common  occurrence under these
 unfavorable circumstances, and we should always be guarded in our
 prognosis, though the case  may  present much less discouragement
 than the  one which I have mentioned.  Here, also, the best chance
 of benefiting the patient permanently can  only be obtained before
 the disease has extended itself to other  parts; and, if  they are al-
 ready involved  when we are first consulted, it will be too late for
 us to recommend  an  operation;  for the case is of a hopeless  de-
 scription.  But, operate when we will, we shall find that, in a large
 majority  of cases, the disease will show itself again in  some part of
 the body or another, and  bring on fatal consequences.   Thus, in
 one case, where Mr. Cline  had removed the testicle for  medullary
 disease, another tumor of a similar nature formed  in the lumbar re-
 gion*, and  by  its  pressure  destroyed the  bodies  of the  vertebrae
 near it, so as to  injure the medulla spinalis, occasioning  paralysis
 and fatal consequences.  This case is recorded  by Sir  Benjamin
 Brodie.  As,  however, we  have  no medicines,  nor  applications
 that have the power of  stopping this malignant form of disease,  the
 knife is the only means  that can  be resorted to, with any prospect
 of success, and  this, as I have explained, is very  uncertain.   In
 some cases, medullary   disease and cystic  sarcoma, appear to be
 blended together in the  testicle, as well as in the absorbent glands,
 which happen to become affected.  This  modification of the  dis-
 ease is as bad,  and difficult to control, as  where no cysts are pres-
 ent, and the morbid mass is simply a medullary substance.
  The rule of  operating early, if an operation is to be  performed at
all for medullary disease of the testicle, is inculcated by every sur-
geon, whose judgment  is worth having.   It is only at  this period,
that there is any hope of other parts of the system not  participating
in the disease.   Possibly, in some few instances,  the disorder may
be at first strictly local,  and afterwards become a constitutional one,
by reason of the absorption of the medullary matter into the system.
* See also Cruveilhier, Anat. Pathol, liv. v. p. 4. 
226         DISEASES  OF  THE  GENITAL  ORGANS.

In a former part of this work, however, I have described the com-
mon characters of this terrible disease, and mentioned the situation
and  organs in which the medullary matter  is found.   Sometimes
the absorbent vessels, leading  from the  disease, have been found
full of a cerebriform substance; a  fact, which Sir Benjamin Bro-
die regards as giving some probability to  the  hypothesis, that  the
disease may thus,  from  being  at  first  local,  become more widely
diffused, and extend from one to several organs in the body.  We
may therefore operate early, though we are  sure  that the case is  a
medullary tumor.   But if  we  have doubts, we should first  try the
plans that were recommended for the cure of chronic inflammation,
or enlargement of the organ,—in particular, the free use of mercury,
iodine, and other alteratives.  If these fail, and we are certain that
it is not a hydrocele which  we are dealing with, we may conclude
that the testicle  is disorganised, and  that,  in all probability,  the
disease is medullary.   If there be any suspicion of fluid in the tunica
vaginalis, we should introduce  a trocar before we resort to  castra-
tion; for the puncture will do no harm to the testicle,  if it be  already
disorganised by medullary  disease; and if the case be a  hydrocele,
with a thick tunica vaginalis, the light  thrown on the nature of  the
complaint will save the patient from a dreadful mutilation.

                 SCIRRHUS  OF THE  TESTICLE,

Exhibiting precisely  the same  morbid structure as in the breast,  is
accounted by some of the best pathologists  a very  rare disease,  if
it exist at all.  Sir Astler Cooper  doubts whether  a hard swelling
of the testicle, intersected by a net-work of strong fibres or bands,
has any existence.  However, we meet with solid, heavy, particular-
ly indurated, almost cartilaginous enlargements of the  testicle, with
a tuberculated feel, severe pains in the part, the cord, and the lum-
bar region;  some fluid in the tunica vaginalis; and,  at length,  fol-
lowed by anasarca  of the lower extremities.   The  patient's coun-
tenance is sallow, he becomes surprisingly emaciated, and at length
he sinks under impaired  digestion, constant suffering, diarrhoea, and
loss of rest.   This is the kind of disease, which the  late Dr. Bail-
lie described as scirrhus of the testicle.  Certainly,  though, in tex-
ture, the  part affected  may not correspond  to other examples of
scirrhus, it does so in malignancy  and incurableness.   Here,  the
early extirpation ofthe diseased organ  is as strongly  indicated as  in
fungus haematodes.   If the case should be too far advanced for an
operation, and the part be ulcerated,  all we can usefully do, is  to
palliate the patient's misery with opium, hyoscyamus, morphia,  and
other narcotics, at the same time applying the nitric  acid lotion, the
liquor opii sedativus, the chloride  of  soda wash,  or the carrot  or
fermenting poultice; or  one made  with bread  and  water, with a
proportion of the extract of hemlock, or henbane mixed wilh it. 
HYDROCELE.
227
                         HYDROCELE.

  The common hydrocele is a collection  of serous fluid in the tu-
nica vaginalis, producing a pyriform,  fluctuating, and, generally, a
more or less transparent swelling in the scrotum.   I have seen it in
persons of all ages, but less frequently in boys than in adult subjects.
The swelling commences opposite the lower part of the testicle, un-
attended with pain; at all  events, the cases in which pain is felt at
the beginning of the complaint, are not the most common.  At first,
the tumor  is soft, and readily  allows the testicle to be felt through
the fluid; but, by degrees, ii becomes tense, and then  the testicle
can no longer be  perceived.   The largest  part of this  pyriform
swelling is below, its diameter lessening gradually  as it approaches
the abdominal ring.   It is only after it has attained a certain magni-
tude, that its weight and tension cause uneasy sensations in the low-
er part of  the back.
  In a dark room, if a lighted wax taper be held close behind one
side of the scrotum, and the swelling be viewed from the opposite
side, while the surgeon's hand is placed over the  external portion of
the tumor, the transparency will generally be very manifest.   It will
always be  so if the fluid be clear, and the tunica vaginalis,  cremas-
ter, and other coverings,  be not too much thickened.   This thick-
ening is found to  prevail chiefly in large hydroceles; but, as  Sir
Benjamin Brodie has noticed, sometimes it occurs where the tumor
is but  of diminutive size;  and then, if we have an  opportunity of
examining  the parts after  death, we find the inner surface of the tu-
nica vaginalis exhibiting a slightly honeycomb appearance, which is
suspected  by  the latter gentleman to denote,  that the hydrocele be-
gan with inflammation.
  Another symptom of hydrocele is the fluctuation, which on the
surgeon grasping the scrotum, and propelling  the fluid forwards,
 maybevery plainly distinguished, except when the tunica vaginalis is
of considerable thickness.   When  the tumor is of some  size, the
testicle is  commonly placed about two thirds of the  way down the
posterior part of the cavity,  a circumstance deserving recollection
when we are about to  introduce  a trocar for the  discharge of the
fluid.
  Sometimes hydroceles  take place on both sides of  the scrotum.
  A lthough  a hydrocele is  mostly of a  pyriform shape, with the
thicker part of the tumor  downwards,  it may assume other shapes.
Thus, if much pressed upon by tight smallclothes, or any thing
else, the form of the swelling may be altered by  that  circumstance.
Perhaps,  however, a deviation of the disease  from  its  common
shape  may not always be referrable  to a cause that  we can trace.
ni the museum  of University College is a preparation, in which,
In addition to the  principal cavity  of the hydrocele, there is  ano- 
228          DISEASES  OF THE GENITAL ORGANS.
 ther pouch freely communicating with it.  Sometimes the hydrocele
 forms two swellings, with the hour-glass contraction between them.
 If we puncture the lower  compartment of such a hydrocele, we
 may  discharge the  fluid from both, which proves that  they commu-
 nicate.   Such is  the usual  state of the case: but it sometimes
 happens that the two compartments do not communicate, a  perfect
 septum being interposed between them.  We are  to believe, how-
 ever, that the communication is open for a time at the contracted
 part, but that, in consequence of the adhesive inflammation,  or oth-
 er causes, the constricted part is at length entirely  shut.   Sir Ben-
 jamin Brodie records an interesting case, proving that  a  hydrocele
 is sometimes  divided in this manner into two  portions,  perfectly
 distinct from each  other.   In the  case alluded to, the  first time the
 hydrocele was punctured, the trocar was passed  into the lower cav-
 ity, which emptied both this and the upper one.   About a year af-
 terwards,  the  same method was repeated;  but the upper swelling
 could no  longer be  emptied in this manner, the incomplete contrac-
 tion  having become  a complete  one  in  the  course of  twelve
 months.
   Some hydroceles communicate  with  the cavity of the abdomen,
 in consequence of  the upper part  of the tunica vaginalis continuing
 unclosed.   This case,  which is  termed congenital hydrocele,  is
 seen  principally  in children, but  occasionally in  adults  likewise.
 The quantity of fluid in hydroceles, which have existed some time,
 is mostly about eight or ten ounces; but Gibbon, the historian, who
 was attended by the late Mr. Cline, had a  hydrocele,  from which
 six quarts of fluid were  drawn; and  many  instances are recorded
 of the tumor reaching  down  to the knees.   Such an occurrence
 can only be the result of great neglect.
   The fluid is also subject to variety in its quality  as well as quan-
 tity.   Sometimes it contains flakes of fibrinous matter,  the product
 of inflammation.   The fluid  is generally very transparent, and of
 an amber or pale straw color: it  is also coagulable by heat,  acids,
 and alcohol, and resembles the serum of the  blood, except in hav-
 ing less albumen in  it.   Sometimes, however, it is  of a much high-
 er color, and even  reddish,  particularly when the case has originat-
 ed  with a degree  of inflammation about the parts.   We also meet
 with certain cases,  in which loose  cartilaginous or osseous substanc-
 es are contained in  the fluid.  Occasionally, small, shining,  greasy
 particles  are observed in it,  which are probably adipocire.  In par-
 ticular instances, the  fluid,  instead of being clear, is  quite  turbid
 and opaque, a circumstance  generally proving, that the inner sur-
 face of the tunica vaginalis  has  been previously the seat of an in-
 flammatory process.
   When a hydrocele is complicated with a loose cartilaginous body
in the tunica vaginalis,  Sir Benjamin Brodie believes, that the loose
cartilage  is  the original disease, and that it is the irritation of  it 
HYDROCELE.
229
which  keeps up the increased secretion of fluid within  that mem-
brane.   If the extraneous substance could be felt, and secured  in
one place directly after the  discharge of the fluid, we should cut
upon it and take it out.   This proceeding  would, no  doubt,  bring
about the radical cure of the  hydrocele, both by removing its cause,
and by exciting a degree of  inflammation.    Sir  Benjamin  Brodie
relates  the  following case:—A  patient with hydrocele, whom he
used to see occasionally for  some  years, always experienced vast
suffering whenever the fluid was let out.   On those occasions, the
patient invaribly threw himself on the  floor,  and  groaned dismally
for a quarter of an hour.   After his death, it was ascertained, that
the tunica vaginalis  contained a cartilaginous  body, which, whenev-
er the  fluid had  been voided, appeared to have  been the cause  of
the patient's agony.
   In hydroceles of long standing, the tunica  vaginalis, the cremas-
ter, and the cellular tissue, are often excessively  thickened.   Ex-
amples also occur, in which  that  membrane has ossifications upon
it.
   The testicle itself is usually healthy; sometimes,  however, tri-
vially increased in size; sometimes rather lessened.   The  testicle
may  also be diseased, constituting what is termed hydrosarcocele.
   Among the best diagnostic signs of a hydrocele, I would specify
its transparency, its fluctuation, its commencement at the lower part
of the  tunica vaginalis, its gradual extension  upwards, its pyriform
shape,  and the circumstance  of a portion of  the spermatic cord be-
tween  the abdominal ring and the upper part of the  swelling remain-
ing free and unsurrounded by the fluid.
  We  are able to discriminate a hydrocele from a sarcocele, or dis-
eased testicle, by the latter being much  heavier, more globular or
oval, and  flatter, at the  sides  than a hydrocele; by its being also
more solid, and productive of a peculiarly sickening pain when  com-
pressed;  by its being attended with a greater degree of pain in the
loins, and very frequently  with  an unhealthy sallow look, which  is
not by  any means a characteristic  of a hydrocele,  which is  often
seen  i.i very healthy persons.
   Then a hydrocele may generally be known from  a hernia, by the
present or previous  possibility of reducing the latter, the impulse  in
it on the patient's coughing,  the  direction in  which the tumor has
passed, its course from the abdominal ring downwards into the  scro-
tum and not upwards to the ring,  its lying over  the upper part of
the cord, and, if the case be a bubonocele,  and not  a  congenital
hernia, by the possibility of  feeling the testicle below the swelling.
   But  sometimes a  hydrocele is conjoined with a  hernia.   Under
these circumstances, we  generally  find, that the  hydrocele lies in
front of the hernia,  and if we should be called upon to operate for
the latter disease in  a state of strangulation, it would  obviously be
the safest mode of proceeding first to lay open the  hydrocele.
  vo£. n.                   20 
 230          DISEASES OF THE GENITAL ORGANS.

   A hydrocele,  though not a very painful  disease in its ordinary
 states, is a considerable annoyance; for it  interferes with all active
 pursuits, and the tumor is much exposed to the  effects of external
 violence.  When large, it draws over it likewise a great part of the
 integuments of the penis, which appears  buried, as it were, in the
 swelling,  so  that  the  disease is  certainly a  serious  obstacle to
 coition.
   I have seen a few cases, in which hydroceles were accidentally
 burst by falls or  blows.  The result is various;  sometimes one of
 the veins of  the tunina vaginalis being ruptured,  hemorrhage takes
 place into the cavity  of that membrane, and  the h)drocele is con-
 verted into what is termed hematocele.  In other instances, tunica
 vaginalis is rather more extensively  torn, and the fluid of the hydro-
 cele passes into the cellular tissue of the scrotum, the  original tu-
 mor subsiding for a time, but almost always returning after the open-
 ing in the tunica vaginalis has closed again.   However,  if much in-
 flammation were  to ensue, the  hydrocele might  be  radically cured
 by the accident;  but the termination will commonly not be so for-
 tunate.
   Hydrocele of the tunica vaginalis, I  mean the common form  of
 it in adult subjects, that which comes on without  pain, very seldom
 undergoes a spontaneous cure.  Sir Benjamin  Brodie  gives one
 example, however, of such an  occurrence.   Probably,  whenever a
 spontaneous disappearance of a hydrocele takes place,  the event is
 owing to some previous accidental inflammation of the parts, or the
 effusion has happened as the effect  of  inflammation, on the subsi-
 dence of which the fluid is absorbed again, and  the vessels resume
 their proper action.
   Treatment.—In children the disease, when not attended  with a
 communication between the cavity of the abdomen and that  of the
 tunica vaginalis, may  generally be cured by lotions containing the
 liquor ammon. acet.,  the hydrochlorate of  ammonia, or other ingre-
 dients calculated  to excite the absorbents.   Iodine ointments rubbed
 into the scrotum, friction with soap liniment, strengthened with the
 tinct. cantharidum, or blistering the  scrotum, as  practised by  Du-
 puytren, will also frequently succeed.
   The common hydrocele of adults will rarely yield to  such plans,
 and we  are obliged to resort to other measures.  Now the nature
 of our proceedings should be chiefly regulated by the consideration,
 whether  the patient is desirous of temporary or  permanent  relief;
 in other terms, whether he is willing to submit to what is called the
palliative, or the  radical treatment, which latter  is necessarily at-
 tended with more pain.   The palliative treatment simply consists
 in discharging the fluid by means of a small trocar and  cannula.
 We  are to grasp  the  back portion of the swelling with the left hand,
 and puncture it in the  central  line,  about  two thirds  of the  way
 downwards from its uppermost part, taking  care to incline the point 
HYDROCELE.                      231
of the instrument a little upwards.  In choosing a trocar, we are to
be careful that it is well adapted to the  cannula, and, in particular,
that the extremity  of the (latter does not form too great a circular
projection on the trocar by being too wide or too thick; for when
this is the case, the  entrance of the trocar into the tunica vaginalis
will be very likely to be stopped  by the circular prominence of the
cannula, and then  we shall either not get the cannula into the hydro-
cele at  all,  or succeed only by forcible and repeated trials, which
give the patient considerable pain, and form a display of awkward-
ness not likely to keep us in  favor  with the  party operated upon.
Attention to minute things in the practice of surgery, such as  the
make  of a trocar,  is often of great  importance to a man who values
his professional reputation; and I have known serious mischief done
by inattention to the construction of this instrument.   Having with-
drawn the trocar,  and let out the  fluid, during the flow of which we
must keep the cannula  well introduced (for if it slip out of the tuni-
ca vaginalis  we shall not be able to put it in again), we may place
a bit of plaster over the puncture, and apply a suspensory bandage,
which latter, however, is not essential, and is often dispensed with.
  If any accidental circumstance bring  on inflammation after  the
operation, it may lead  to a complete cure; but this only happens in
a small  proportion of cases, and hence the method, now described,
is called by  surgeons the palliative  treatment.
  The  radical consists in discharging the  fluid,  and then adopting
some  measure calculated to excite inflammation of the testicle,  or
rather of the inner surface of the tunica vaginalis.   We  may fulfil
these  indications by different proceedings. About half a century ago,
surgeons sometimes applied caustic to the scrotum, which produced
a slough, the separation of which was followed by the issue of the
fluid,  and the requisite inflammation of the tunica  vaginalis.   This
plan   was at  length  renounced  as  unnecessarily  severe,  and
uncertain of success.    At  the same  period,  the  practice  also
prevailed of passing tents aud setons into the tunica vaginalis for the
cure of  this  disease.   The seton was in favor for a long time, and
even  now,  though  not used for  the present form  of hydrocele,
is sometimes employed in  another variety of it.    Then, another
plan of  cure consisted  in making a  free  incision into the swelling, so
as at once to let out the fluid, and make such an exposure of the
cavity of the hydrocele as was followed by inflammation, suppura-
tion,  granulation,  and  the obliteration of  it.    This last mode
of treatment is still advisable undet particular circumstances.  But,
in general, the  best practice, and  that to which all  the most ex-
perienced surgeons in this  country give  the preference,  is  to
discharge the fluid, and immediately  afterwards  to  throw  some
stimulating fluid  into the cavity of  the tunica vaginalis, for the pur-
pose of bringing on the  necessary  degree of inflammation.   This
operation requires  a simple  but  well-made apparatus, composed of 
232         DISEASES  OF THE  GENITAL ORGANS.

a trocar and cannula, and either a  syringe  with a pipe adapted to
the cannula, or else an elastic gum  bottle with  a  brass neck, fur-
nished with a stopcock, and of a size exactly adapted  to the mouth
of the cannula.   Some surgeons use an injection  containing sul-
phate of zinc;  others, employ a solution of alum, or brandy and
water.  Port wine and warm  water in equal proportions, were pre-
ferred by the late  Sir James  Earle.   Of late,  an  injection,  corn-
posed of 5ij. of tinct. iodinii,  and  3vj.  of tepid water, has been
used, on the ground, that the cure is sooner accomplished by means
of it than other injections, a larger quantity of  which  is also stated
to be necessary, so that  the passage of some of it into the cellular
tissue is more likely to happen.  The port wine and zinc injections
are the only ones, which I have hitherto employed.    The wine in-
jection should be  made stronger than what  is  above specified; if
two thirds of it be wine,  it will not be too stimulating.   1 have also
frequently  put 3iss. of the sulphate of zinc into a pint of warm wa-
ter, and believe that the chance of a failure of the operation is there-
by lessened.   The fluid of  the hydrocele having been discharged,
and  the elastic bottle filled  with the lotion, we push the end of the
stopcock into the mouth of the cannula, and throw the  injection into
the tunica vaginalis.   Before we  do this, however, we are to be
sure,  that the internal end of the cannula  has  not receded  from the
cavity of  that membrane;  for  if it  has  done so, the  injection will
pass,  not into that cavity, but  into the cellular tissue of the  scrotum,
and bring on extensive abscesses, or  even a dangerous  sloughing
of the parts.  I remember  once assisting a surgeon  in this opera-
tion, and telling him to be on his guard  against this  accident, the
risk of which he seemed  to think very trivial.   He  told me that he
had tapped numerous hydroceles without  the occurrence;  and yet,
from not paying attention to keep the cannula  well in during the
discharge of the fluid, and the shrinking of the  tunica  vaginalis, the
very thing now happened  which he considered to be impossible un-
der his management.   Abscesses and some gangrenous  mischief
followed;  but I believe the  hydrocele was radically cured, which
might not have been the result.  On the average, the injection may
be kept in from five to ten minutes.   In young  persons, three min-
utes  will  suffice.   The  quantity of injection should  not  be  quite
equal to the quantity of fluid discharged,  because if we distend the
tunica vaginalis too much, some of the injection is apt to flow out
by the side of the cannula into the cellular tissue, and occasion sup-
puration, or even sloughing.   If*the testicle should be affected with
chronic enlargement, this  circumstance ought not always to deter
us from employing  the injection, which, in such a case, has  often
brought about a cure.  After  the operation, we  are to put a  piece
of adhesive or soap plaster over the puncture, and when inflamma-
tion has come on,  apply a poultice.   At  one time it was supposed,
that this method could not produce a  cure, except  by obliterating 
HYDROCELE.
233
the cavity of the tunica  vagiaalis, or by exciting the adhesive in-
flammation in it, followed by the union of  the loose tunica vaginalis
to the portion of it reflected over the testicle;  and that, unless such
union took place, the hydrocele  would return.  But it is now well
ascertained, that a hydrocele is often cured without the cavity of
the tunica vaginalis being  obliterated, and on  another principle,
namely,  the  injection excites  inflammation of the interior of that
membrane, followed by some permanent  change in the state  and
action of the vessels of the  part, whereby   they are prevented from
continuing to secrete a redundant quantity  of fluid; and there seems
to be a restoration  of the due equilibrium between secretion  and
absorption.
   With  regard  to the variety  of hydrocele, in which  its cavity is
divided into distinct bags or cells, one ciucumstance merits notice,
namely,  that we cannot treat it  efficiently, or, indeed, with the slight-
est prospect of a cure,  by injection; and the  proper plan is that of
making a free incision into the  tumor, and discharging the fluid from
the several  pouches in  which it is  confined.   Thus a radical cure
may be  accomplished with tolerable  certainty.   In  some  cases,
where a  hydrocele is found to  have two distinct  cavities, this  pe-
culiarity  depends upon a hydrocele of the tunica vaginalis being com-
bined with an encysted hydrocele of the spermatic cord.
   In all  ordinary cases, the treatment by  injection should  be pre-
ferred, as the  mildest and surest.  Where, however, the hydrocele
contains  several different  cavities,  not communicating together,
where likewise the nature of the disease is doubtful, or the case is
variously complicated with a hernia, or the presence of a hernial
sac, or the method of injection has already failed,  it  may be  the
most prudent  course to practise  an incision, in  preference to a
puncture, and  this, under some of these  circumstances, even with
extreme  caution.   When,  however,  the   doubt  is, whether  the
disease is hydrocele or a medullary tumor,  a puncture with  a  small
trocar seems to  be  followed  by no ill  consequences; and  it is, I
think, preferable to an incision, which, in the event of the case be-
ing hydrocele,  would  be an  unnecessarily severe  mode of  cure.
When an injection has  not  answered,  the  seton may be employed,
if the surgeon  prefer it, as a milder practice than the treatment  by
incision.   In a few such cases, I have tried acupuncture with suc-
cess;  but in others without it.   In  two or   three examples, I have
resorted  to  acupuncture after  a  partial  return  of hydrocele,  and
completed the  cure.   If acupuncture  be  tried,  pressure  may  be
combined with it.
   We should never proceed to puncture a hydrocele of the tunica
vaginalis, without  having examined  it most carefully;  for various
cases  are recorded,  in which  the  testicle, instead  of having the
fluid  in front of  it,  has  been adherent to  the front of the interior
surface of the tunica vaginalis,  and actually been wounded with the
                           20* 
234          DISEASES OF THE GENITAL  ORGANS.
trocar, none of  the fluid collected  at the sides of this  body  being
discharged.  One of the best ways of avoiding this serious error is
to examine every hydrocele with a wax taper, in the manner already
specified;  for  if the  forepart of  the tumor seem opaque, and, when
compressed, occasion the  sickening  pain always arising from com-
pression of the testicle, we may infer, that this body is adherent to
the front of the cavity of the hydrocele, and would be wounded by
the introduction of the trocar in the usual place.

                    CONGENITAL  HYDROCELE

Signifies a collection of water in the  tunica vaginalis, attended with
a  narrow  communication between the  cavity of the latter  mem-
brane and the interior of the peritoneum.   In the foetus, the testi-
cle is contained in the abdomen, whence it descends into the scro-
tum, generally a little while before  birth, but sometimes not till after
this event.  The production of the peritoneum, by  which it is ac-
companied, and which is  to constitute  the  future tunica vaginalis,
usually  closes'  soon  after the descent of the testicle is completed.
But before this happens, fluid may pass into it from the cavity of
the peritoneum, and  a peculiar form of  hydrocele, termed congeni-
tal, be the result.  This case has one symptom that does not charac-
terise other hydroceles; namely, pressure makes the swelling disap-
pear by  forcing the fluid up into the cavity of  the peritoneum.  In
this respect^ then, we see a similarity to  hernia.  The  hydrocele,
however, is a  transparent, soft, pyriform swelling, in which a fluctu-
ation can be plainly  felt.   A congenital hydrocele not only dimin-
ishes or disappears under pressure,  but also when the patient lies on
his back; resuming its ordinary shape and dimensions as soon as he
puts himself in the erect posture again.   It  may  take  place either
when the testicle has descended properly into the  scrotum,  or when
it  has not descended, and is not even perceptible; or  it may occur
while the testicle is somewhere in the inguinal  canal, or can be felt
just at the abdominal  ring.  In these latter cases, the tunica vagi-
nalis is elongated and extended from  the place where the testicle is
lodged down into the scrotum.   These are  circumstances very ne-
cessary to be remembered,  because  they influence  the treatment.
This must  be manifest, because we cannot prudently attempt any
thing for the cure of the hydrocele  that would interfere with the de-
scent of the testicle, or be likely to injure it.
   The best mode of treating congenital hydrocele, when  not com-
plicated with a retarded descent of the testicle, is to apply a truss;
for thus we at once remove the danger of a protrusion of the bowels,
and promote the closure of the passage between the scrotum and the
belly.   No sooner has the  obliteration of the opening been accom-
plished, than a further supply of fluid  from the cavity of the perito-
neum is cut off, and  what is contained  in the tunica vaginalis is ab- 
HYDROCELE  OF THE  SPERMATIC  CORD.        235
sorbed.  This practice is more advisable than the old method of cure
by  means  of a  stimulating lotion thrown into the tunica  vaginalis,
while an assistant made  pressure at  the ring, in order to keep a por-
tion  of the fluid from  entering the cavity of the  peritoneum.   I
deem the treatment by means  of a truss more advisable; first, be-
cause unattended with any risk of bringing  on peritonitis; and sec-
ondly, because it is adapted to  expedite the closure of the commu-
nication between the scrotum and the belly,—a  desideratum which
is entirely out of view in the treatment with injections.

            HYDROCELE  OF  THE SPERMATIC  CORD

Is much less frequently met with than hydrocele of the tunica  vagi-
nalis, and is commonly  described as an accumulation of fluid in a
thin membranous cyst within the sheath of the cord.   Sir Benjamin
Brodie, indeed, regards this encysted hydrocele  as corresponding
to a cyst filled with fluid, produced in any  other organ of the body,
and takes notice of its  loose connection to  the surrounding parts.
While, however, Sir Astley Cooper  admits this mode of formation,
he conceives that,  in certain examples, the  production  of the dis-
ease is owing to the adhesion between the peritoneal investments of
the cord happening to  be imperfect  in one  place, so as  to leave a
cavity between them.   This is also Scarpa's explanation, who pub-
lished,  many years ago, an interesting memoir on the present  com-
plaint.  The swellingjis generally oblong, or globular;  and, if it be so
placed as to admit of being grasped and pushed forwards,  it will often
present a light blue color, with a degree of transparency about it, and
considerable tension.  Few specimens of it attain much magnitude, its
ordinary size not exceeding that of a pigeon's egg, and pain is not one
of its characters. We now and then hear, or read, however, of a large
one, including several ounces of fluid.   When situated in  that part of
the cord which is within the inguinal canal, the tumor is liable  to be
mistaken for hernia, though I may observe, that  it is free from  pain,
as well as  from  the guggling sound or feel perceptible  in intestinal
herniae, and that the functions of the alimentary  canal are not in tho
least disturbed or interrupted.   Though such a tumor may be forced
a little way up the  inguinal canal, we cannot bring about its perfect
reduction.    When the  tumor  is on the outside of the  abdominal
ring, we recognise  its nature by various circumstances.   We advert
to its transparency, its  fluctuation,  its giving no sudden  impulse to
the  finger  when the  patient  coughs, and to its  being  unconnected
with any of  the organs in the  abdomen, even though it  may  admit
of  being pushed into  the ring.   Under  these or  any other circum-
stances, it  can never be put completely up  into the belly, and,  when
left to itself, it  soon descends into  its  usual place, above which
the cord is free.
   The fluid of  a hydrocele of  the  spermatic cord is generally  paler 
236          DISEASES  OF THE GENITAL ORGANS.
and  more limpid, than that of a common  hydrocele, and  contains
less albumen.
  One  of the  best  modes of treating this disease is,  to  make an
incision in it, and then  fill the cavity  with lint.   In the  case of a
lad in University College Hospital, I removed a slip of the front of
the cyst, and the disease was soon  cured.   Another  eligible plan
of treatment consists in passing a seton of two or three threads or
silks through the swelling.   These  may be introduced in  the way
recommended by Sir Astley Cooper,  with a common curved  nee-
dle.   The latter method deserves the praise of mildness, and I be-
lieve is  tolerably certain of answering,  though, perhaps, less so than
the treatment by incision.  If we fill the cavity with lint, after lay-
ing it open, there will be no occasion for the removal of any portion
of the cyst, in  which proceeding there is some risk of doing injury
to the vessels of the cord.   The  cavity will  suppurate, granulate,
and soon be obliterated.
  Hydrocele of the spermatic cord, when small,  produces little or
no inconvenience; and, on  this account, some  practitioners scarcely
consider it  as a case requiring the  performance of any operation.
If, however, the  patient's mind is rendered continually uneasy by
the tumor, or the tumor should be in any way a source  of  inconve-
nience,  or show a disposition to enlarge, it is right to attempt its
cure.   Injections have so often failed  ip the treatment of this form
of hydrocele,  that they are now abandoned in this  metropolis.
  Besides this  kind of encysted hydrocele, there are other varieties,
situated  on  the epidydimis, or the testicle.  The former lies, as
Sir Benjamin  Brodie has  explained, between the epidydimis and
the inner layer  of the tunica vaginalis;  the latter between this mem-
brane and the  tunica albuginea.

                         HEMATOCELE,

Which, etymologically speaking, means  simply a  tumor composed
of blood, at the present day always denotes  a collection  of blood
in the tunica vaginalis.  The swelling is of a pyriform shape, like
hydrocele, from which it may be distinguished by  its want of trans-
parency, its greater weight, its obscure fluctuation, and  the manner
of its production;  the cause  being  usually a blow on the  scrotum,
or a wound  of  an artery, or vein of the loose  portion of the tunica
vaginalis, or an injury of the testicle itself.   Sometimes, I suspect,
an enlarged or diseased vein gives way spontaneously, after the water
has been discharged from the tunica  vaginalis, and, continuing to
bleed into the  cavity of this membrane, leads to the  formation of
haematocele.   We  know, however, in  many instances, that a largish
vessel has been  wounded, for the fluid of  the  hydrocele, as  it
flows out, is more or less mixed and tinged with blood.   If a lancet
be  used for this  purpose,  the risk of haematocele is increased. 
HEMATOCELE.
237
Some persons have become  the subjects  of haematocele in  conse-
quence of a blow on the testicle from the  pummel of the saddle, in
riding on horseback;  and, in such  cases, probably the  bleeding is
often from the vessels of the testicle itself.
   Some time ago, I visited with Mr. B. Cooper a gentleman, who
had a large hydrocele  on  each side of the  scrotum,  and  one of
these he had converted  into a haematocele by a trial of his  own in-
genuity.   Perceiving that all that a surgeon did,  when he  let out
the fluid, was to make  an opening  in the  swelling, he  fancied that
he could invent an instrument that  would  make the attendance of a
surgeon unnecessary.   After a little study, he contrived an instru-
ment, very much like what is used by farriers for bleeding horses,
only it was on a larger scale; the blade, which darted out on touch-
ing a spring, being something like  a dagger.   With this weapon he
perforated the swelling, indeed, and let out the water, but wounded
some  of the  blood-vessels,  so  that in  a few hours  the tumor
was  as large as ever, and a great  deal more painful.   In short, the
cavity of the tunica  vaginalis had  become  distended  with blood.
The blood soon began  to putrefy,  the parts inflamed, considerable
fever ensued, and, partly from the constitutional disturbance and the
approach of  gangrenous mischief, the patient's life was in clanger.
If a prompt and free incision had not been made, I fully believe his
condition would soon have  been hopeless.  By  this  operation a
considerable quanity of  putrid blood,  matter, and a most offensive
gas, sulphuretted hyodrogen, having been discharged, the patient re-
covered very  favorably.
   One hydrocele was radically cured by this proceeding; 'but,  not-
withstanding the inflammation was considerable, it  had not the ef-
fect of curing the other hydrocele.
   Haematocele is only painful when complicated with inflammation,
or with mechanical injury of the testicle.    Some cases, therefore,
are  painful, and others not so.  In certain examples, a haematocele
is combined with hydrocele: this may take  place when  a person,
who has a  hydrocele, receives a severe contusion of the scrotum,
and  one or more blood-vessels of  the tunica vaginalis  are ruptured
by the violence, and the blood, which flows from them, is added to
the fluid already in the tumor.  The state of the case may be known
by the previous  accident,  the sudden increase of the swelling fol-
lowing the  injury, and the dark opaque  appearance of the tumor,
which  no longer exhibits its former  transparency,  when a lighted
taper is placed behind it.
   The treatment of haematocele varies according to circumstances.
When the quantity of blood  is inconsiderable, we should not inter-
fere with it by any operation, but endeavour to promote its absorption
by means of brisk purgatives and  lotions  containing vinegar, spirit,
and  hydrochlorate of ammonia.   The absorption of a more copious
effusion of blood in the tunica vaginalis is not likely to be accomplish- 
238          DISEASES OF  THE GENITAL  ORGANS.

ed;  for we hear of cases in which the blood continued nearly twenty
years unremoved, though changed in its appearance, and turned into
a pale brown lamellated substance, very much like what is met with
in an old aneurism.  Sir Astley Cooper gives one instance, in which
he cut into a  haematocele that had existed seventeen years and in
which the blood, originally effused, still remained, though in an alter-
ed condition.   When  haematocele  arises from  a blowr,  antiphlo-
gistic treatment at first  is  the  most  prudent;  we are to  keep the
patient quiet in the recumbent posture,  and try  what benefit can
be obtained from purgatives,  leeches, venesection, low regimen, and
cold evaporating lotions.   In a later stage,  if the swelling should
continue of any material size, or threaten to bring on suppuration,
sloughing, and other troublesome or urgent consequences, we should
of course make a free incision into  the tunica  vaginalis,  discharge
the blood collected in it, and then apply emollient poultices, unless
there was a tendency to a renewal of bleeding, to which circumstance
linen, wetted with cold  water, or the  Saturine lotion, would be bet-
ter than  warm  applications.
   If the  disease  were  combined with hydrocele, or to follow the
puncture of the latter kind of swelling, I should lay open the tunica
vaginalis, take out the blood, and then apply warm or cold applica-
tions,  according as there might or might not be a disposition to a
return of bleeding.  In almost all cases of haematocele,  requiring
an operation,  antiphlogistic  means are indispensable at first; and I
have seen several  cases in which it has been necessary, on account
of the inflammation and constitutional disturbance,  to employ the
lancet and other  means of depletion very freely.   In cases where
the effusion  of blood follows the puncture of  a hydrocele,  that is,
where there is  a communication  formed between  the cavity of the
tunica vaginalis and the external  air,  the blood soon putrefies, and
becomes a source of considerable  irritation; matter forms; a ten-
dency to sloughing is  produced;  sulphuretted hydrogen  gas is gen-
erated in the swelling; and the patient gets into an urgent state of
danger, from which the formation of  a free and immediate opening
into the disease is  the only means of extricating him.

                  VARICOCELE,  OR CIRCOCELE,

Consists of a varicous enlargement of the spermatic veins; the dis-
ease being more common on the  left side  than the right, in conse-
quence, as Morgagni  believed, of the termination  of the  left sper-
matic in  the renal  vein, the  current of the blood  in which is not in
the direction of the left  spermatic vein,  as the course of the blood
in the vena cava is, with  reference  to that of the right spermatic
vein.   In former days, the first of these terms was  generally restrict-
ed to a mere varicous dilatation of the veins of the scrotum, an affec-
tion  requiring  no  particular  notice; while the expression circocele 
VARIOCELE, OR CIRCOCELE.
239
was used  to  denote more particularly a  varix  of the spermatic
veins themselves, a case more deserving of consideration, because
surgeons are often consulted for it, and it  occasions a  swelling that
has frequently been mistaken for hernia.   In the present day,  these
two terms are mostly  employed  synonymously;  and  when  we
hear of a  modern surgeon speaking of varicocele, he is almost inva-
riably alluding to a morbid enlargement of the spermatic veins, and
not of  those of the scrotum.   When the veins of the  cord are thus
altered, they assume a tortuous  course, their coats are considerably
thickened, and the  vessels have a knotty feel, attended with a greater
fulness  below the  ring  on the diseased  side than the  other, and
with more or less uneasiness,  sense of weight, and occasionally a se-
vere pain  in  the testicle, inguinal canal, and loins.  The swelling is
sometimes large,  and of a pyramidal shape, with the base just above
the testicle.   When we examine a varicocele with the  hand, we feel
the cluster of dilated veins, which are commonly described as commu-
nicating a sensation, as if we  were taking hold of a bundle of earth
worms.  We may distinguish varicocele from a hernia, by placing the
patient in  the recumbent posture, and pressing the blood of the large
veins upwards, or returning the  protruded viscera,  so  as to reduce
the swelling; we then cover  the abdominal  ring with our  fingers,
and desire the patient to rise while we keep the fingers thus steadi-
ly over the ring.   Now, if the case be a varicocele,  the spermatic
veins   fill  again, and assume their former distended condition direct-
ly the  patient is in the erect   position, notwithstanding the abdomi-
nal ring is covered and compressed; but if the case  be a  hernia, no
protrusion can happen, while  we keep our fingers on  the ring, and
consequently, so long as they are thus applied, there can be no re-
turn of the swelling, though the  patient change his posture from the
recumbent to the erect.   The swelling of varicocele, when  it re-
turns, makes its appearance also in a more gradual manner  than a
protrusion of the abdominal viscera.
   In the  generality of  cases, varicocele  is not a very painful dis-
ease, and  the patient  finds any uneasiness  from  it relieved by sup-
porting the testicle  with a suspensory  bandage or a silk net, by bath-
ing the scrotum  and  groin  with cooling  lotions, and keeping his
bowels regular.   If there be  greater  annoyance,  or any  severe  de-
gree of pain, he should, in addition to the  foregoing measures, ob-
serve the  recumbent posture,  and apply leeches.   In a few  rare in-
stances, the sufferings produced by varicocele have been such as to
induce the patient to submit to castration;  but, in the  present state
of surgery, I  am reluctant to  believe that such proceeding is  justi-
fiable.   Another  experiment  has consisted  in  putting a  ligature
round (he largest of the varicous veins;  bui by this we  should ex-
  ?ose the patient  to the risk of phlebitis;  and  one of the  late  Sir
  iVerard Home's  patients  nearly lost his  life after such an opera-
tion.   Some practitioners have had recourse to another plan; after 
240         DISEASES  OF THE  GENITAL  ORGANS.

dividing the integuments, they have compressed the most distended
veins between the blades  of forceps  constructed  for  the  purpose,
and thus obliterated their cavity.  Fricke's method consists in pas-
sing a seton of three Or four threads through the bundle of varicous
veins.  One of the most serious occasional  consequences of the
disease, and also of treatment of it with  the forceps, is atrophy of
the testicle.
   [In cases of circocele, when it is necessary to have  recourse to an
operation, I have succeeded with the needle  and  twisted suture.  I
first separate the vessels from  the vas  deferens  with  the  thumb  and
fingers,  and then puss a long  needle  behind  them,  and apply  the
thread over the needle as in the  hare  lip suture.   But litile pain is
experienced, at least for a day or two; if much  inflammation  follow,
the patient should  be kept in the recumbent position, diet low, bow-
els open, and cold  applications should  be made to the  part.   I allow
the needle  to remain  until  the  vessels below it are hard and cord
like.
   I operated in May, 1844, upon a young man twenty-one  years of
age, and modified the above operation,  by  dividing the scrotum over
the vessels after the needle was introduced, and  then the suture as it
was twisted, lay between the lips of the wound,  and in this  way,  the
pain from the strangulation of the skin was avoided.  My friend Pro-
fessor Gross from Kentucky, suggested this modification.— Ed.]

                  DISEASES  OF THE SCROTUM.

   The scrotu m is liable to anasarca and  ecchymosis, which, how-
ever, are here attended with no peculiarity, no  circumstances  dif-
ferent from those accompanying such  affections  in other common
textures of the body.   It is also  occasionally the seat of phleg-
monous erysipelas, and then,  from its abundance of  loose cellular
tissue, which becomes distended with a serous  fluid, is  productive
of a considerable  degree  of swelling,  often extending to  the very
end of the prepuce, and causing there a phymosis.  On first sight
of such a case, where  the swelling is equal in size to a child's head,
the suspicion at first raised is, that the urethra has given way,  and
that the urine has been effused.  Whether this has really happened
or not, free incisions should be made; and, if any  doubt exist about
the state  of the  urethra, a catheter  ought to be introduced,  and
kept in, as it can do no harm, even if the urethra  should be sound,
and, in the opposite case, will be of essential service in preventing
the further escape of urine into  the cellular tissue of the perinaeum
and scrotum.   The scrotum is sometimes the  situation of tumors;
and I remember one case in St. Bartholomew's,  where an excres-
cence in the shape of a horn, and  of a horny  consistence, was form-
ed on it.   In warm climates, the scrotum is often converted into an
enormous mass of adventitious or  hypertrophied cellular tissue, of-
ten amounting to half a hundred-weight or more, and not only bury- 
                 CHIMNEY SWEEPERS' CANCER.            241

ing, as it were, the penis and testicles,  but absolutely disqualifying
the patient for exercise or any kind of employment requiring loco-
motion or muscular  exertion.  Now and  then a similar distressing
disease has been seen in Europeans; Delpech operated upon some
remarkable cases of this kind, in one of which the swelling weigh-
ed  seventy or  eighty pounds.   In Mr.  Liston's collection is ano-
ther tumor of this nature, which he removed, and the weight of which
must be very great.   It is generally,  however,  in  warm climates
that the disease is  met with.   Larrey relates the particulars of sev-
eral cases which he saw in  Egypt,  and  facts  of the same  kind
abound in the records of surgery.   The  case of a native of China,
who  died under the  operation attempted  for his relief  in Guy*S
Hospital, must be fresh in the memory of all surgeons in London.
Many successful  removals  of the  diseased mass,  however,  have
been performed,  especially by Clot Bey, in Egypt;  and  it is the
only expedient that can afford relief, where the patient's life is ren-
dered a  burden  by the magnitude of the  adventitious formation.
In practising these operations, there are three principal points to be
attended to: first,  we are to take care to secure every large artery
as soon as divided, so that the patient may not  die of hemorrhage
before the operation is finished;  secondly, we are to avoid injuring
the testicles and urethra;  thirdly, we are to give the patient a cor-
dial draught, or a little brandy with a proportion of laudanum in  it,
before the operation, so that his nervous system  may  be  better en*
abled to bear the long and unavoidable agony, or  the  shock, of the
operation.

                 chimney-sweepers'  cancer

May be strictly denominated a disease of the scrotum; for the in-
stances, in which it has  been known to commence in other part3 are
very unusual.   It  seems to arise  from the  lodgment  and  irritation
of soot in the rugae of the scrotum; and, perhaps, if other parts of
the integuments were as well adapted  for the reception and deten-
tion of this substance, we  should  more  frequently notice  the dis-
«ase in them.   A  few cases, in fact, are related,  in which the dis-
ease occurred on the face and limbs, and this even in  persons who
were not  chimney-sweepers;  but then it is to be observed they
were gardeners, or laborers in some other way, requiring them  to
handle soot.  The disease commonly begins in the form of a small-
ish  wart or induration upon the scrotum, such wart or induration
soon presenting a  broken  surface,  from which a  particularly foetid
matter is poured out, but, drying, is converted into a kind of scab,
or incrustation.   From time to time this  is rubbed off and followed
by a more and more copious effusion of very offensive bloody ich-
or.   At  length, an  ulcer  of some extent is produced under the
scab, with hardened, everted, or contorted margins.   In  time, the
  VOL.  n.                   21 
,242         DISEASES  OF  THE  GENITAL  ORGANS.
 ulcer reaches the  tunica vaginalis and the  testicle, and rhe absor-
 bent glands in the groin swell,  burst, and  sometimes  change into
 similar malignant ulcers.  I  have known a  chimney-sweeper's can-
 cer commit such ravages that the artery  in  the groin was laid  bare
 by it.   In some cases, indeed, the patient dies of profuse bleeding;
 but more usually he dies hectic, exhausted by irritation, long suffer-
 ing,  profuse discharge, and extension of the disease to the lympha-
 tic glands in the loins.
   This is a malignant disease, over which internal medicines and ex-
 ternal  applications possess little or no control.   If, therefore, we
 meet with the disease  in its early stage, before the testicle, the sper-
 matic cord, or the lymphatic glands are  involved,  we ought to  lose
 no lime in trying useless medicines and  dressings, but at once  take
 away the disease with  a knife.   Even then  the result will be uncer-
 tain;  and, in the course of my time, I recollect more instances, in
 which  the operation was followed  by a  relapse, than  a permanent
 cure.   I attended, at the Bloomsbury Dispensary,  a  chimney-
 sweeper afflicted with the disease in the state of ulceration, with one
 or two glands in the groin enlarged, which seemed to me a prohibi-
 tion to the operation.   He  went  into one  of the  hospitals, where
 the diseased portion of the scrotum was removed;  but, I am inform-
 ed, he soon died  of a return of the disease higher up in the body.
 By these remarks, 1 would  not  wish it  to  be  supposed, that the
 operation will never succeed when the inguinal  glands are swollen.
 I am sure it  will  not  answer, if  those glands participate  in the
 morbid action; but, if they  be merely enlarged from irritation, then
 a cure may be the result, ihe glandular enlargement gradually sub-
 siding after the disease  has been removed.   About two years ago,
 I operated under  these circumstances  on  a chimney-sweeper  in
 University College Hospital; and, though the inguinal glands after-
 wards suppurated, the  man was cured in a few weeks.   The same
 thing, it is well known, is occasionally noticed  after the removal of
 a scirrhous breast.
   One  remarkable difference  between  chimney-sweeper's cancer
 and common cancer is this: in the  former case, if the whole of the
 diseased parts be taken  away, there will be no relapse; in the latter,
the same practice  will  not secure the patient from a return  of the
disease in the same or  other parts.

                    CANCER OF  THE PENIS

 May commence on  the glans, or  the prepuce, and afterwards not
 only involve both these parts, but  extend its ravages much further,
so as to cause excessive induration even  in  the corpora cavernosa
themselves, and sometimes  to destroy the  greater  portion  of the
penis, by a process of malignant ulceration as high  up as the pubes.
In the museum of  University College is  a fine specimen of scirrhus 
CANCER  OF THE  PENIS.
243
of the penis, in which the corpora cavernosa and septum penis are
involved;  it was taken from an old man, who was under my care as
a patient of the Bloomsbury Dispensary, and whose water I  used
to draw off' daily for some  time before be died.   At certain times,
he suffered  acute pain in the organ, which was much enlarged, and
the hardness of which was  very  remarkable.  His great  age, the
state of his prostate gland, and the diseased condition  of his blad-
der, prevented me from proposing the removal of the  penis.   He
died, indeed, from a complication of diseases, and not exactly from
scirrhus of the latter organ.   In many instances, the disease origi-
nates in the form of a warty induration, either  on the inner surface
of the prepuce or on the glans, and  it may continue  in this  state
many years, without much change, though more generally it is soo
followed by ulceration, the  discharge of a thin peculiarly offensive '
ichor, and the formation of a  malignant sore, with hard everted, or
contorted, edges.   In the  case of the old  man to which I  have al-
luded, the disease had  existed a very considerable time, without
getting into the  ulcerated  stage.  The  late Mr.  Hey, of Leeds,
took  particular  notice,  that,  in many instances  of  cancer of the
penis, the patients had a natural phymosis;  for, in eight  out of ten
examples, which he attended, this was the case.   The observation
was corroborated by the  reports  of M.  Roux, of  Paris.   Mr.
Travers has never known a Jew to be the subject of cancer of the
penis; but he operated on a man, who  had been cut for phymosis ten
years previously, in whom a pimple on the side of the fraenum ulcerat-
ed, and assumed the form of cauliflower fungus, completely surround-
ing the glans, while the latter  continued sound.   Perhaps, the fol-
lowing consideration  may  explain why many cases are combined
with  phymosis,  which may not  in  every  instance  be  natural, or
have preceded the  other  disease: when a cancerous  affection be- ,
gins on the inner surface of the prepuce, or when a cauliflower in-
duration exists  either there or on the  glans, the irritation of the
prepuce,  arising from such a cause, may lead to a swelling, thicken-
ing, and  enlargement of that  part, just as we know that  common
warts, in  the  same situation,  frequently do.   Yet, I  believe, that
congenital phymosis does not  predispose to cancer of  the  penis, as
Mr. Hey suspected;  for, undoubtedly, those who have a long pre-
puce, and neglect cleanliness, are more liable to disease within that
part than others, whose foreskin  is short.   Sooner or  later, after
scirrhus or cancer has begun  in the penis, the glands in the groin
enlarge, and the ravages of the disease may gradually  extend  from
the extremity of the  penis to  the pubes, and have a fatal  termina-
tion.   Other ill-conditioned, or fungous diseases of the penis, how-
ever,  must  be  carefully  discriminated  from  cancer.    I should
say, with  Mr. Travers,  that  whenever the  disease  begins  as an
irritable pimple of the  glans, or  prepuce, and this breaks  into a
spreading ulcer, within an indurated base, and a disposition to throw 
 244   DISEASES OF THE GENITAL  AND URINARY ORGANS.

 out a fungus, the case must be viewed with great suspicion, whether
 the glands in the groin be affected or not, particularly if the pntient
 has passed the age of fifty.
   The only chance of freeing a patient from a cancerous disease of
 the penis depends upon the timely removal of the affected  portion
 of the organ with the knife.   The earlier this  is done, the greater
 the prospect of success; for,  when the inguinal glands are  involved,
 the operation  is too  late.   Trivial sympathetic swellings  of those
 glands, however, are not accounted by every surgeon a just prohibi-
 tion of the operation, though  the discrimination  of such enlargement
 from one of truly scirrhous kind is by no means easy.  One thing
 has been fully proved by repeated experience, namely, that the pa-
 tient is not certain of not having a return of the disease, though the
 operation be done at a period when no glandular enlargement exists.
 When the disease returns, it  may either  reappear upon the stump,
 or in the shape of  cancerous  buboes in the  groin, which, after  a
 time, often bleed profusely,  so as to bring the patient very quickly
 to his doom.

             DISEASES  OF THE PROSTATE  GLAND.

   A swelling of  the  prostate  gland may be of different kinds, and
 depend upon a variety of causes: thus it may originate from com-
 mon inflammation of the part, abscesses, calculi within its substance,
 a  varicous enlargement of the veins in its vicinity, or a chronic al-
 teration of its texture, by which its shape, size,  and consistence are
 materially affected.   This latter  case, though attended with great
 induration of the part, and often termed  scirrhus, is different from
 any cancerous affection,  not  betraying any disposition to affect  the
 lymphatic glands, or to communicate a truly  scirrhous form of dis-
 ease to other textures and organs.  The gland itself, when examin-
 ed, does not  present the  texture of scirrhus, but is a dense, com-
 pact, nearly homogeneous  substance.  Whatever danger attends it
 (and great danger does frequently accompany it) proceeds from the
 difficulty of passing the urine,  and its injurious effects on the bladder
 and kidneys,  to  which such  state of  the prostate  gland, when  far
 advanced, inevitably leads.    The  prostate  gland,  besides being
 liable to the several affections which I have mentioned, is  also sub-
ject to scrofulous disease and  abscess; and perhaps, when  a chronic
 enlargement of it takes place in a  young person,—one under the
 age of thirty, for instance,—there is reason to suspect the affection
 to be scrofulous; for the other chronic enlargement, to which I have
 adverted, rarely happens in persons much under fifty.
   With respect  to  acute  abscesses,  1 believe  they  are generally
formed  around, or in the vicinity of,  the prostate gland, and not in
its substance.   They may  occur,  however,  in  the cellular tissue,
between its, lohes.  Most of  the examples which I have  see^ fol- 
DISEASES OF
THE PROSTATE  GLAND.
245
lowed  suddenly suppressed  gonorrhoea, or were produced by the
irritation of strictures  in  the urethra.   They interfered seriously
and urgently with the evacuation of the urine; and consequently re-
quired free  and prompt  incisions for the discharge of the matter.
Sometimes  they  burst  inta the urethra, or make their way out in
the perinaeum.  All  inflammatory complaints about the neck  of
the bladder and the prostate gland generally cause more or less diffi-
culty in passing the urine; and such is the ordinary effect of abscess-
es in this situation.   In  the  early stage, we should  employ every
means in our  power, calculated  to  prevent  the inflammation from
advancing to suppuration; and,  for this purpose, we should apply
leeches freely to the perinaeum, bleed from the arm, administer calo-
mel and brisk purgative draughts, and employ  fomentations,  or even
the warm bath.  But, directly matter has formed,   the  sooner  an
incision is  made the better.
   With regard to prostatic calculi, they are composed of  phosphate
of lime, their.size varying from that of a pin's head  to that of a nut.
Sometimes they pass into the urethra,and are discharged. When they
cause much annoyance, and can be felt from  within  the  rectum  on
the finger being introduced into this bowel, they should be removed
by making a suitable incision into the gland with the aid  of a staff.
When they project  into the urethra,  a similar operation will be re-
quired.  If possible, they should always be  extracted without ac-
tually cutting into the bladder itself.
   The disease of the prostate gland, most interesting to the prac-
tical surgeon, is a  slow enlargement of it, by which its bulk is some-
times enormously increased, from that of a chestnut,  its natural size,
to that of a large orange, or  even a melon; for  it has been known
to attain the magnitude of fifteen times  its natural size.   The mu-
seum of University College  is particularly  rich  in specimens of
diseased prostate  gland,  bladder,  and urethra.   One preparation
exhibits the bladder with the prostate gland, not only much enlarg-
ed, but torn or  fissured by the repeated  attempts of the surgeon  to
get the  instrument  into  the  bladder.   Small calculi are lodged in
the bladder in the  depression  behind  the  prostate;  and  we learn
from the history of the  case,  that  an abscess had formed between
the bladder and rectum, which burst  by an opening,  which is still
discernible, into the former of these organs.
  Chronic enlargement of the prostate gland is most commoijin the
decline of life,  at which period there  is a natural  tendency to  it,
such that, in persons of advanced age, this part is always  increased
in size.   The alteration of the prostate gland does not usually ren-
der the contiguous portion of the urethra narrower,  in the  manner
of a stricture, but compresses the sides of that canal together, and
either bends it more suddenly  upwards,  pushes it to  one side,  or
turns it in spiral or other diversified modes.   These  facts  enable  us
at once to understand why this disease of the prostate gland should
                            21* 
246"  BtSEASES or THE genital  and  urinafl* O'R'G'AN'ff;

Fender the patient liable to retentions of urine, and why he  should
have symptoms and complaints very similar to those of stone.
   The urethra has  been known to be widened.   Thus, Sir  Benja-
min Brodie has recorded a case of  diseased prostate  gland, where
the urethra was dilated into a sinus,  capable of holding two or three
ounces of urine.   The urethra, however, is generally more  or less
compressed and distorted,  at the same time that it  bends  more sud>-
denly up into  the  bladder.  In consequence  also of the prostate
gland acquiring an increased magnitude, the prostatic portion of the
urethra must  necessarily be lengthened;  and this may  happen in
such a degree, as to make the  urethra two or three inches longer
than natural.   Frequently the gland is more enlarged on one side
than the other; a circumstance that  gives more or  less obliquity to
it.   As the principal part of the prostate gland naturally lies below
the urethra, the greatest part of the swelling occupies the same place-
In many of these cases,  there is a swelling of a portion of the gland
just behind the vesical orifice of the urethra.  Such a swelling may
act like a valve at the neck of the  bliadder, and, in many prepara-
tions,  it is actually  seen  constituting a large prominence in the blad-
der, attended  with  the effect of mechanically forcing the urethra for-
wards towards the  pubes, and of obstructing  the passage of instru-
ments, or of preventing the surgeon from readily  touching  with  a
sound a calculus situated behind and below it.   In one specimen in
University College,, the prostate gland is irregularly enlarged,  and
one part of it  projects  into the bladder, so that it was wounded in
the attempts to introduce the catheter.  Small calculi are also ad-
herent to the inner surface of the bladder.  In many of these cases
of enlarged prostate, there are calculi in the bladder:: in another pre-
paration  in the same  museum, several calculi form a very  serious
complication of the other disease.
   This chronic enlargement of  the  prostate gland  comes on slowly
and insidiously, not indeed exciting attention  until the size  of  that
organ generally, or of the third lobe in particular, begins to bring on
first a frequent desire  to make water, and occasional tenesmus, or
uneasiness about the rectum,  followed,  after a time, by more or
less difficulty of voiding  the urine.  There  is  not only  pain in
making water, but  a desire and straining  to  discharge more, after
the bladder has been emptied as far as  it  can be.  The muscular
coat  o£ the bladder, being  obliged to exert itself very frequently, and
having a mechanical  obstacle, as it  were, to overcome, becomes of
course considerably thickened.  In  fact, in an early stage of the
disorder, the patient  finds  that he is obliged to make a greater effort
than  usual to get the urine to flow;  he is compelled to strain a good
deal  ere it will begin to escape; but when once the first difficulty is
surmounted, the contents  of the  bladder pass out tolerable well.
However, in  proportion as the diseased gland continues to increase
in size,  the  difficulty of  passing the water also increases; more' 
             DISEASES 0*F  THE  PROSTATE  GLAND.         247

Straining is always required, and  at times there is a complete or in-
complete retention.   No doubt, in a great number of instances, the
projection of the third lobe, as it is sometimes termed, just  behind
the vesical orifice, has a  mechanical effect *n obstructing the dis-
charge of urine; and  probably if is when such prominence begins,
that the inability  to empty the bladder with  perfect facility is first
experienced.   In one  preparation in  the museum  of University
College, the  projection resembles a nipple in shape; in another it
represents a complete ridge.   Sometimes, when the third  and one
of the lateral lobes project considerably into the bladder, their sur-
face has an irregular ulcerated appearance, and on  this account the
patient suffers aggravated pain in expelling the last drops  of urine,
as well  as distressing attacks of spasm  at the neck of the bladder,
symptoms also noticed in cases of stone.   An ulcerated state of the
projecting portion of the gland will also explain  the  great disposi-
tion to hemorrhage,  exemplified in some of these cases on  the in-
troduction of a catheter.
   In all advanced cases, the patient is annoyed with distressing irri-
tation about  the rectum,  tenesmus, and flatulence; and a  desire to
go to stool often takes place  so suddenly and irresistibly, that it is
with great difficulty he can reach the proper place for relieving him-
self.
   Generally, the patient voids large quantities of a viscid  ropy mu-
cus from the urethra, which was supposed by the late  Sir Everard
Home  to be derived from  the prostate gland itself.    No doubt, a
great deal of  it is secreted  by the inner coat  of the bladder, which
sometimes becomes  the seat of inflammation.
   In a  considerable proportion  of these cases, after a  certain pe-
riod ,not only is the muscular coat of the bladder much thickened, but
the inner coat protrudes between the  muscular fasiculi in  the form
of cysts, or little sacs.  A sacculated bladder,  as it  is termed, is a
frequent complication of enlargement of  the prostate gland.  Now,
these cysts may also include calculi, and instances have been known
in which they were filled with pus.   But this is not all the mischief
resulting from disease of the prostate gland; for, amongst  other bad
consequences, the complaint, by deranging the functions of  the uri-
nary organs, may bring on, and frequently does  bring on,  a morbid
enlargement  of the ureters, and fatal disease of the kidneys.
   Several of the symptoms of diseased prostate gland are  like those
of stone in the bladder; but, in the former case, the patient is able
to bear exercise and  the motion of a carriage much better than in
the latter disorder.   In a case of stone,  there is also less  tendency
to retention of urine, but a greater disposition to paroxysms of vio-
lent pain  in  the hypogastric  region, and to the  discharge  of blood
with the urine after exercise.   I occasionally visit an old gentleman,
who  has long had a  considerable swelling of the prostate gland, yet,
except at  periods when he is laid up with retention  of urine, he is
able  to walk into  the city daily.  In all doubtful cases, the state of 
248  DISEASES OF  THE GENITAL  AND  URINARY  ORGANS.

the prostate gland should be examined from the rectum,  and the pa-
tient sounded.
   The  museum of  University  College contains  one specimen in
which, besides the enlargement of this  organ, a considerable thick-
ening of the muscles of the ureters is seen, and likewise sacs form-
ed by a protrusion of  the inner coat between  the  fasciculi of  the
detrusor urinae, from one of which  sacs a culculous had been  ex-
tracted.   In another specimen, the prostate is very much increased
in size,  while  the  muscles of  the  ureters form a ridge adapted  to
give lodgment-  to  calculi.   Another preparation  is the  bladder of
an old man, who died  of retention of urine.   The prostate is vastly
enlarged,  its lateral  portions rising up, and its naturally posterior
part projecting forwards; whereby the course of the urethra was so
altered, that no instrument  could have been  introduced, unless it
had been  forced through the substance of the gland.
   An enlarged prostate  is  an awkward complication of a case of
stone, not only because it sometimes carries  up the neck of  the
bladder almost above  the  pubes, and  removes  the cavity of that
viscus very far from the perinaeum,  but because it  may create  im-
pediment  to the passage  of a staff, and certainly will render the  op-
eration more difficult and protracted.
   Another instructive  preparation is a bladder with diseased pros-
tate gland, and four  calculi in  the former viscus.   The third lobe is
enlarged.   In trying to introduce the catheter, the surgeon forced
it between the bladder  and rectum;  and the patient died.
   I do not know whether disease of the  prostate usually produces
a tendency to  disease  of the rectum; I suspect  that it does, more
especially hemorrhoids.  In the above museum is a diseased  pros-
tate, complicated not only with a thickened sacculated bladder, but
with stricture of the  rectum.
   One occasional  effect of  disease of a prostate  is a vast  dilation
of the ureters.   In the above-mentioned collection is a tuberculated
enlargement of the prostate gland, with the mouths of the ureters
remarkably widened.
   In another specimen of diseased  prostate, taken  from a patient
who died  of retention  of urine,  there is  a fungous  mass projecting
from it into the bladder.   The preparation also affords a specimen
of the anatomical luses of three  ureters.
   In the treatment of  chronic enlargement  of the prostate  gland,
occurring in persons above the middle period of  life, we are to re-
member,  that it is  an organic disease, for  the removal and complete
cure of  which no surgeon possesses any effectual means.   Yet, not-
withstanding this disagreeable  truth,  it is some consolation to know,
that surgical assistance  is  often of  essential service; and this  not
merely by obviating  some consequences, which  would be likely to
abridge the patient's life, and even  cut him off very abruptly,  but
by rendering the usual  inconveniences of the complaint much  more 
DISEASES OF THE PROSTATE GLAND.
249
bearable than they would otherwise be.   By  the due regulation of
the stomach and bowels  with alterative and aperient medicines;  by
directing the patient  to avoid sitting long at table after dinner, and
not to expose himself to wet, cold  weather, the stoppages of  urine
are rendered much less frequent, and the annoyance from tenesmus,
flatulence,  &c, ordinarily experienced by patients  laboring under
the disease, materially diminished.   Setons and  issues in the  near-
est part of the  perinaeum to the prostate gland have  been tried; but
I have never seen any good from them; and the same observation
applies to various internal medicines, with respect to their power of
reducing the swelling of the gland,  especially  iodine, mercury, and
hemlocks...
   A retention of urine, arising from this  disease of the  prostate
gland, will not often yield to the warm bath, opium, or hyoscya-
mus;  and the reason of this fact seems to be explained by the con-
sideration, that the obstruction  is less of a spasmodic nature than
of  a mechanical  description.   Local  bleeding is occasionally ser-
viceable, and, as a degree of spasm may, and probably  does con-
tribute, with the mechanical effects of the disease  on the urethra,
to prevent the discharge of urine, I conceive  that, when a catheter
cannot be immediately introduced, the surgeon ought not entirely to
neglect the trial of the warm bath and  opium in the form of an ene-
ma, though he  should  not place much confidence in them, nor de-
fer the use of the catheter.   In fact, it is  always best to resort to
the catheter at  once,  because a prompt discharge of the urine  is the
only method of preventing the  ill effects of a  forcible distention of
the bladder.  The bladder itself rarely or never  bursts  in  these
cases,  even if the water be not discharged; but the constitutional
disturbance increases, the action of the kidneys is interrupted, the
inner coat of the bladder inflames, and  the patient  dies comatose.
I have seen examples, in  which, when  the water  was  drawn off,
it had a completely purulent appearance, and no recovery followed;
and Mr. Travers has seen two cases  of long  retention  of  urine
from  disease of  the  prostate gland, where the mucous membrane
lay like a slough, loose in the bladder.
   The catheter used in these cases ought  generally to  be of full
size, greater length than  common ones, and rather  more bent up-
wards towards  its beak.   Some  cases  require the catheter  to  be
thirteen or fourteen inches in length, as a shorter one will not reach
the bladder.   The late Sir Everard Home, who had considerable
experience in the treatment of disease  of the prostate gland,  pre-
ferred  elastic  gum catheters,  so constructed, that  they retained a
particular curve, even when the stilet  or wire was withdrawn from
them.   These  he sometimes left in the urethra  several  days;  for
they were calculated to bear warmth and moisture better than  other
common ones of the elastic kind.   For the  purpose of  retaining
them in the passage more surely and conveniently, a catheter brace- 
250  DISEASES  OF THE GENITAL AND URINARY  ORGANS.

let was employed.  A flexible catheter should be preferred to a sil-
ver one,  when it is  deemed most advantageous to keep the instru-
ment any time in the passage; for it will remain  there with  much
less  annoyance than a metallic one.   But, on the other hand, we
are sometimes able  to  pass a silver  catheter, when we cannot  suc-
ceed with one made of elastic gum, which,  unless the wire  be of
unusual thickness, has not always  sufficient firmness to overcome
the impediment arising from the compressed state of  the urethra, or
the alteration of its course.    In these cases, whatever catheter be
employed, it generally passes jo the anterior portion  of the prostate
with perfect facility, and here its beak is stopped, sometimes  partly
by the compressed  state of the urethra, but chiefly by the new  cur-
vature of the passage, which we cannot always get an instrument to
follow.   In fact, there are few instances of considerable enlargement
of the prostate gland, without the urethra included in it being  pro-
pelled forwards and upwards, or to one side, or twisted in various
ways.   Perhaps, where the  passage is tortious, an elastic catheter
of moderate size  is the most  likely to find its way; and this instru-
ment has one advantage over a silver one, deserving   to be well re-
membered in practice, namely, by withdrawing the wire at the pe-
riod when we are trying to make the instrument pass the obstruction,
we are able suddenly to increase its curvature, and  thus often  suc-
ceed in getting it  into the  bladder when no silver catheter  could be
introduced.
   Generally it is  necessary  either to leave the catheter in the  ure-
thra, or to draw off the water once or twice  a day, according to
circumstances,  removing it directly after each evacuation.  These
plans are to be continued, until the patient regains the power  of ex-
pelling the urine himself.  When the case is such, that the introduc-
tion  of the catheter is always difficult, the wisest plan, after getting
the instrument into the bladder, is  to keep  it introduced for  a  few-
days, and, as soon as the  patient can empty the bladder by his  own
power, it may be withdrawn.  An  elastic gum catheter, if it can he
passed,  should here  be  preferred.  A  surgeon should always bo
provided  with  catheters  of  various kinds,  diameters, lengths, and
curves; and one  improvement, made  by Sir Benjamin Brodie, I
consider  entitled to  commendation, namely, that of having the han-
dles  of the wires  of elastic catheters  made  large like the  handle of
a staff; for thus we acquire a greater command over  the instrument,
and can guide its beak with greater precision and delicacy.   I ap-
prove also of the  wires  being thicker than those in common  use,
and of the plan of keeping some catheters  prepared, so  that  they
will retain their curvature  after the wire is taken out  of  them.
  The gum catheters which Sir Benjamin Brodie prefers, are mount-
ed, not on small flexible wires, but on strong iron stilets, having the
curve of a silver catheter.  The  stilets of  the larger ones have flat
iron handles resembling those of common sounds.    Gum  catheters 
STRICTURES OF
THE URETHRA.
251
should be  kept thus  prepared for a considerable time before they
are used; they will then have the proper curvature.   Sir Benjamin
Brodie tries first to pass the gum catheter without the stilet;  if he
fails, he then tries the instrument wilh  the stilet.   In the  present
disease, large catheters are more easy  of introduction than small
ones;  and the stilets  of  elastic  catheters ought to be  considerably
curved.   In  passing them,  it  is now  a common plan to keep the
handle, at first,  close to the left groin, introduce them as far as pos-
sible in this position,  then bring the handle  forwards nearly to a right
angle with the pubes, and  the handle is then to be depressed slowly
and gently by placing  one finger on it.   When this is  done, the
point generally glides into the bladder,  though sometimes this does
not happen till the stilet is withdrawn.   In particular examples,  it
is necessary to bend the point forward by means of a finger within
the rectum, or on the perinaeum.
   If no catheter can  be  introduced, we  must either  puncture the
bladder  above  the upbes, or form a passage through the  diseased
mass of  the prostate.   At the same time, I  may  observe,  that we
can almost always succeed with a catheter, and that puncturing the
bladder is rarely called for.

                STRICTURES OF THE  URETHRA.

   A  stricture of the  urethra may be defined  to be such a  contrac-
tion or alteration of a part of the  passage,  that here it becomes
considerably narrower  than  what it is  by  nature, or even  entirely
obstructed.    With the subject of strictures,  however, it is  usual  to
consider several states of  the urethra:  as first, the irritable urethra,
as it is termed;  secondly, spasmodic strictures; and,  thirdly, per-
manent strictures.  Respecting the  irritable  urethra, I believe the
term is rather employed for its convenience than its precision; and,
generally, what  is said  upon this reputed irritability of the   urethra,
is vague and of little value.   Frequent desire  to make water, and
more  or less uneasiness  in  passing it, are  commonly specified  as
symptoms of an irritable urethra: occasionally attended also with a
discharge.   Now,  these effects  may result  from so  many various
causes, that really it is difficult to admit the propriety of taking them
as proofs of an  irritable  urethra.    Any inflammation in the urethra
will cause the symptoms;  so  will an  incipient stricture in certain
constitutions.
   Now, nothing shows more clearly the unsettled notions,  attached
to the subject of irritable  urethra, than  the widely  opposite modes
of treatment adopted for its relief by different practitioners. Thus,
some  surgeons treat it by  prescribing, three times a day, one eighth
of a grain of  the  bichloride of mercury,  and 3J. of nitrous  spirit
of aether: some, referring it  to  disorder  of  the  digestive  organs,
prescribe the blue pill and sarsaparilla;  some, viewing it as connect- 
 252  DISEASES  OF THE GENITAL AND URINARY ORGANS.

 ed with the inflammatory state of the canal, employ leeches to the
 perinaeum, and take blood from the loins by  cupping; some, judg-
 ing that it is the same thing as the alleged spasmodic stricture, give
 hyoscyamus or  compound powder of ipecacuanha;  while  others,
 regarding it merely as too sensitive a state of the passage, endeavor
 to blunt its  extraordinary tenderness by  the occasional introduction
 of bougies.
   The division of  strictures into  spasmodic and  permanent  is not
 satisfactory to all surgeons,  some of whom have a difficulty  in  be-
 lieving, that the  lining of the urethra  is endued with  muscularity.
 The observations of John Hunter maintain the latter doctrine, in
 favor of which several facts are usually adduced.   Thus, a man, if
 otherwise healthy,  voids his urine one day in a  full stream;  on the
 following day, he exposes himself to damp and cold, or takes  punch,
 or acidulous wine;  and next morning he cannot void his urine;  but
 is relieved by  going to bed, taking a dose of compound powder of
 ipecacuanha, and, after having had  the bowels emptied by medicine,
 he passes his water as well as usual.   Then the effect of large bou-
 gies, or nitrate of silver, in  enabling another patient to make water
 in a considerable stream, is  also adduced as an  argument on  the
 same side of the question.   The difficulty of passing water in such
 cases comes on suddenly, and ceases suddenly; the cause is tempo-
 rary—not a permanent disease.  The canal of the urethra certainly
 varies in its diameter at different periods, and cold appears to have
 great effect in rendering  it narrower.   In practice, it has always ap-
 peared to me, that bougies  and other instruments will enter the ure-
 thra much more  easily in the same patient at  some  periods than
 others; and that  opium,  hyoscyamus, and other narcotics, often fa-
 cilitate the passage of such instruments.   But then it is maintained
 that the  resistance, when it occurs, is  not anterior to that portion of
 the canal which may be conceived  to  be affected  by  the action of
 muscles in the perinaeum.   Abroad, the  doctrine of the muscularity
 of the membrane of the urethra,  and  of spasmodic strictures,  has
 gained, I believe, no advocates.   There, the formation of strictures
 is invariably ascribed to the  effect of inflammation in thickening parts
 of the  canal; and the same  view is  adopted by  Sir C. Bell and many
 other  practitioners in  this   country, who explain  various circum-
 stances, which have been referred to spasm of the urethra itself, by
 the action of muscles in  its vicinity.   A permanent stricture is at-
 tended with a conversion of the contracted part of the lining  of  the
 urethra into a substance of the consistence of ligament, but without
 its fibrous texture.  The contracted part has, it must be confessed,
 no resemblance to muscular tissue.
   One of the earliest symptoms of a stricture is the retention of a
few drops of urine  in the urethra after the patient has made  water,
 which drops soon escape, and slightly  wet the linen; while another
 small quantity, collected between  the neck of  the bladder and  the 
STRICTURES- OF THE URETHRA.
253
stricture,  may be expelled by  pressure  below  the urethra.   The
next thing noticed is, that  the patient cannot retain his water as long
as usual,  but is obliged to  empty the bladder once, twice, or often-
er in the course of the niglit.   As the disease increases the stream
becomes forked,  spiral, or scattered;  and in  a still more advanced
stage,  the water is voided only by drops or altogether stopped, espe-
cially when the urethra is  under the influence of  cold,  irritation, or
the effects of intemperance.   In addition  to these symptoms, the
patient has pain about the  glans penis, and there is commonly a thin
gleety  discharge  from the passage, a circumstance,  which  often
leads to the serious  mistake of treating the case  as if  it were mere-
ly a gonorrhoea or gleet.
   In consequence of the natural sympathy  between the urethra and
testicles,  one of the latter  organs is liable  to be attacked with inflam-
mation, more especially, however, during the use  of bougies.   Whe-
ther a  stricture be at first  merely spasmodic,  and capable of relaxa-
tion, as the Hunterian doctrines teach, is a disputed point;  but it is
universally admitted that,  after a time, the part of the urethra, which
is the  seat of stricture, is thickened, as well as contracted; that the
diminution of this portion  of the canal is not a temporary or periodi-
cal  affection:  in other words, that the stricture is permanent.
   In old  and aggravated cases of stricture, the  bladder usually be-
 comes considerably  thickened, and does not admit of its usual de-
 gree of expansion.   Frequently it inflames,  and pours out a vis-
cid kind of secretion  like pus.  And, when the obstruction in the
 urethra attains a  certain stage, ulceration takes  place  between  the
 bladder and the first and principal stricture;  abscesses form on the
 outside of the  canal, and,  bursting, produce channels for the escape
 of the urine, called, on account of their situation and  their  usual in-
 disposition  to heal,  so long as the obstruction in the urethra is not
removed, fistule in perineo.
   Strictures in the  urethra sometimes give rise to paroxysms of in-
 termittent fever.   I have seen many examples of this fact, and, in
 some  of them, the ague had been treated  without any suspicion hav-
 ing been  entertained of  its real cause.
   A stricture, when examined in the dead subject, is often found
 not to occupy a  great extent of the passage, the contraction  being
 sometimes  not broader, than what would originate from a piece of
 packthread drawn tight round the urethra.   In some cases, however,
 a stricture does not correspond  to this description; but the urethra
 is contracted along a considerable portion of its course,  in which
 event its inner surface  is  exceedingly irregular, and sometimes as
 indurated and tough as cartilage.  In particular instances,  the con-
 traction or diminution of  the tube is only on one side of it;  while,
 in others, it amounts to a  complete circular constriction of the pas-
 sage.
    The most frequent place for a stricture is just behind the bulb of
    vol.  n.                  22 
254  DISEASES  OF THE GENITAL AND URINARY ORGANS.

the urethra, or about six and a half or seven inches from the orifice,
in the anterior part of the membranous portion of the canal.   Per-
haps the situation, next in order of frequency, is about  four and  a
half inches from the extremity of  the penis;  then  three  and  a half;
and sometimes close to the opening in the glans.    Strictures  ante-
rior to the bulb  are less liable  to be  influenced by spasm, if they
can be so affected at all, than other strictures placed more backward
in the canal.  It was the doctrine of  Sir Everard  Home, that, in
the generality of cases,  where only one stricture exists, it is just be-
hind the bulb; and that  if others are  found  more  forward, we are
almost sure of meeting with one in the former situation.
   In  the advanced stages of stricture, there  is frequently a remark-
able  dilatation of the passage  behind  the stricture.   In one case,
under the care of  Sir  Benjamin  Brodie, whenever the patient at-
tempted to make water, a tumor,  as large as an orange,  was formed
in the perinaeum.  When strictures have continued a long time, and
increased to a certain degree, the bladder is required to make greater
efforts than natural to expel the urine, and the result is a great thick-
ening of its muscular coat.  The same change is  commonly seen
likewise in persons, whose discharge of urine is not so  free as it
ought to be; and who suffer occasional retentions of it in consequence
of the effects of disease of the  prostate gland, or the portion of the
urethra  pervading this  body.  In cases of  stricture, when the pa-
tient has repeatedly suffered from retention of urine, it is no uncom-
mon thing to find, after death, the ureters themselves vastly dilated.
I  have  known  them to assume  ;he appearance of two glass tubes,
three  quarters of an inch in diameter, distended  with  transparent
urine.
  Amongst the bad consequences of stricture, is the unfortunate and too
often  fatal occurrence of a rupture of the bladder or urethra, arising
from unrelieved  retention of urine.   The bladder itself sometimes
gives  way;  but far more frequently a portion of the urethra behind
the stricture ulcerates, or sloughs, and  the urine becomes effused.
   It is not an uncommon opinion, that strictures promote the origin
and increase of disease of the prostate gland.  They certainly do
so, inasmuch as  inflammation and abscesses about  it are  concerned;
but I  do not believe that  they have any  share in bringing on the
indolent  enlargement of that gland, so  common in elderly  persons.
Bad strictures unquestionably keep  up- a disposition  to  chronic in-
flammation of the mucous coat of the  bladder, and hence it maybe
thickened, as well as the muscular fasciculi of the detrusor.
   An irritable bladder is a frequent complication or effect  of  stric-
tures.   Then another  change resulting from strictures, is the for-
mation  of sacs  or cysts in  the bladder; a sacculated state of this
organ, which we know is also a frequent complication of  diseased
prostate  gland.
   If strictures are suffered to reach a  certain stage, abscesses form 
STRICTURES OF  THE URETHRA.
255
about the neck of the bladder, the prostate gland, or in the perinae-
um.   I have opened  a good number of individuals, who died from
the effects of very bad strictures; and, in a large proportion of these
cases, I found not only extensive abscesses in the cellular membrane
 of the  pelvis, but disease and suppuration in the kidneys.
   In studying diseases in general,  we should always make ourselves
acquainted,  if possible,  with their causes.  Now,  with regard  to
strictures of the urethra, it is a common belief,  that  gonorrhoea is
the most frequent cause of them; a view, however, that was reject-
ed by John  Hunter, on the ground that most of  the ducts and pas-
sages in the human body,  lined by mucous membrane, are subject
to stricture.  Then, another idea is, that though gonorrhoea  may
not have this effect, the  astringent injections, employed for its cure,
may  bring on  strictures.   This is a point on which the  highest au-
thorities differ.  A long residence in the East  or West Indies, and
the mode of life there pursued, give a disposition to strictures.   At
all events, in the better classes of  society, strictures are particularly
frequent among those individuals who have passed  a considerable por-
tion of  their lives in a tropical climate.
   The  treatment  of permanent strictures is conducted  on various
principles:—
   1st.  On the principle of mechanically dilating the contracted part
of the  urethra with common bougies, catgut  bougies, elastic gum
bougies, metallic instruments, or sounds, or elastic gum catheters re-
tained in the passage.
   2d.  On the principle  of  producing a destruction  of the  stric-
ture  by making it idcerate with  the pressure  of bougies or metal-
lic instruments, or slough from the effect of escharotic applications
to it.
   3d.  On the principle of perforating the obstruction with a conical
sound;  a  plan, however, only  sanctioned  in bad cases, not yield-
ing to milder methods.
   4th.  On the principle  of piercing  the stricture with a sharp in-
strument, introduced down to it through a tube.
   5th.  By cutting down to the stricture, removing the obstruction
with  a knife, and then introducing  a catheter and  healing the wound
over it.
   The  Cure by Dilatation may be regarded as that which, on the
whele, retains the  greatest  share of approbation, though particular
circumstances may sometimes call for  some of the other methods.
The cure by dilatation is accomplished  by  common bougies, flexi-
ble metallic  bougies, and sometimes by means of steel sounds and
silver catheters of various sizes.  They  are all intended to act upon
the principle of a wedge,  and  thus  to dilate the  contracted part of
the canal.   However, the action of such  instruments is  different
from what it would be on inanimate matter; and the  living parts,
pressed upon and  distended by them, undergo certain changes, 
256   DISEASES OF THE GENITAL  AND  URINARY  ORGANS.

which are the result of processes depending upon life.  Thus, the
parts either adapt themselves to the pressure, or recede by ulceration.
  Strong as the symptoms of stricture may  be, which have been
enumerated, we require a more unequivocal proof  of its existence;
and we wish also  to know what part of the  urethra is contracted,
and in what degree.   For this purpose, we first carefully examine
the urethra with a well-oiled  bougie  of  nearly full size; for, if too
small a one be  employed, it may  pass through a moderate stricture
without any stoppage, or it  may  deceive  us  by its point becoming
entangled in one of the lacunae of the mucous  membrane.  All bou-
gies above a certain size should be cylindrical,  or not too conical,
which shape would immoderately distend the orifice  of the urethra.
The stoppage of  the  instrument, together with well-marked  symp-
toms of  impediment to  the free  escape of the  urine,  may be re-
garded as a proof of stricture.  If doubts exist, we should pass a
metallic sound, or silver catheter warmed, and try  whether more
positive information can thus be obtained.
   Supposing a stricture to be ascertained, the next object is to get
as large a bougie through it as it will admit;  but often only a small
one will  pass;  and, if  we can succeed  thus far, we  then know that
the dilatation of  such stricture is  in  our  power; for, after leavihg
this small bougie in the passage for a few  minutes, we find the con-
stricted part of the canal still more  capable of  receiving  this bou-
gie again, or  even  another bougie of  rather larger  size, on the
next trial, which should be made  in a day or two.    This  is next to
be withdrawn,  and  one of still larger size introduced.  In this man-
ner,  we proceed  gradually  from  small  to  full-sized  bougies,  with
which the cure is to be completed.
   With  respect to  the questions—how  often  a bougie should be in-
troduced , and how long kept in the stricture, there is  no  invariable
rule  to be followed; but much must depend upon the  patient's capa-
bility of bearing the bougie without too much irritation.   With this
qualification, I  may observe, that generally the  bougie may be em-
ployed every other day, and be  worn for twenty minutes,  half an
hour, or an hour, if the patient has  favorable opportunities  for it.
The principle is to increase the size of the  bougie, as fast  as the
yielding  of the stricture will allow.
   Of late years,  metallic bougies and  conical  sounds of different
sizes and curvatures, have been extensively employed.  Sometimes
they pass more readily along the  passage,  with  their point directed
to either side;  an advantage which does not belong to common flex-
ible bougies.   The latter also, in consequence  of their bending or
cracking, are not so well calculated for those strictures, in which an
instrument must be used with some  degree of force.  To common
and  flexible  metallic bougies we can  give  any curvature  deemed
proper;  but, with respect to steel and  silver sounds and  catheters,
they are always constructed with  determinate curves, adapted to the
urethra? of different individuals. 
STRICTURES OF  THE  URETHRA.
257
  The advantages of a waxen bougie are, that one of much smaller
size, than any metallic instrument, can be safely employed; because
metallic instruments if constructed of similar slenderness, would be li-
able to break.   I scarcely need  observe, that the minute diameter
of some bougies is an important advantage, when the stricture is
close, and will not admit a larger instrument.
  Small sounds are usually made of silver; the large,  of steel plat-
ed.   I believe it is best to have them but slightly curved, and not
more than eight or nine inches long.  In using them, too much vio-
lence must not be  exerted, which would  make a false passage;  and
we  shall more certainly avoid this risk, if we take care to make the
beak glide along the  upper surface of the urethra.   After having
passed, one of the  sounds,  we  may  repeat the introduction  of it
again in two or three days.  In  many cases it is best to begin  with
small bougies, and then to go on with sounds, in  the manner recom-
mended by Sir Benjamin Brodie.  The latter instruments are fre-
quently advantageous for old gristly strictures, and cases complicat-
ed with a false passage.
  It may be asked, to what size should  we carry bougies, sounds,
and other instruments  used for the removal of  strictures?  In an-
swer to this question I may remark, that some practitioners gradual-
ly proceed to bougies which are thicker  than the little finger; but
I never follow their example, finding that instruments of more mod-
erate diameter answer every purpose.  Bougies act, as  Mr. Hun-
ter  has observed, on the living parts, constituting the obstruction or
contraction: and these  parts recede, or, in  other  words, are  ab-
sorbed under the application of  the instrument, so as not to require
the  passage to be distended in any extraordinary degree.
  In common  strictures, the most successful practice is conducted
on the  principles of gentleness and  skill;  and those surgeons,  who
employ great force and rough manual  proceedings, not only put the
patient to a great deal of unnecessary pain, but  expose him  to the
danger of abscesses in the perinaeum, profuse hemorrhages from the
urethra, and the formation of a false passage.
  It is well known to all men  of experience, that strictures of the
urethra are very liable to return: when, therefore, we  have dilated
the  contracted part or parts of the passage, so far as  is considered
advisable, we should recommend the patient still to use a large bou-
gie  occasionally.   In my opinion,  it  is much better for a man to
pass the instrument himself once a  fortnight, or once a month, for
some considerable  time after the end of the treatment, than to run
the  risk of having  a relapse.
  The method of  curing  strictures with elastic  gum catheters  has
been preferred by  several eminent surgeons abroad to all  others as
a general one.  If we resort to  this method, and  succeed in  get-
ting the catheter through the stricture, it is a good rule to do what
Sir  Benjamin Brodie recommends; viz.  to  let  the instrument be
                           22* 
258   DISEASES OF THE GENITAL  AND  URINARY  ORGAN'S..

kept in the  passage day and night,  for  three  or four days; then
taken out, and  one of larger size  passed, and  allowed to remain*.
This mode of treatment is deemed by Sir Benjamin Brodie advan-
tageous.  1. When the patient's time is of high value; because the
stricture  can thus  be more quickly removed, than  by any other
means.  2. Where the stricture is dense and  cartilaginous.   3.
Where the urethra is irregular, or a  false passage has  been made.
4. Where rigors follow  the use of the common  bougies: for it  is
an observation made by Sir Benjamin Brodie,  that such  rigors are
most disposed to take place when the urine first comes in contact
with a part of the urethra that has just been dilated; which contact
is prevented by  the catheter, through which the bladder should  al-
ways be  emptied.
   In very close strictures, we sometimes cannot succeed in  getting
any  bougie  immediately through  them.  In this circumstance, we
must either endeavor to make way through them by exciting ulcer-
ation,—that is  to  say, by pressing the  end  of the  bougie with
some  force against  the  obstruction  daily  until the part  ulcerates,
-—or try some  of  the  other methods to  which  I  have alluded.
Now, it  was the difficulty of getting  through some strictures, which
led to the employment of escharotics for their destruction.   Ano-
ther reason was also urged in favor of this practice, namely, that it
produced a radical cure;  whereas the treatment,  on the principle of
dilatation, was alleged only to relieve the patient temporarily, as the
stricture generally returned some time after  the discontinuance of
the bougie.  I believe  that, in this respect, one method is not bet-
ter than  the other; and,  whether we use common or  caustic bou-
gies, the patient will -sometimes have a relapse.
   So long ago as the time of Wiseman, red  precipitate  was con-
veyed on the end  of the bougie down to strictures; but it wTas not
till the period of John-Hunter, that  a more skilful way of applying
caustic to them was suggested.   This was by passing a piece of
the nitrate of silver through a cannula, by means of a piece of wire
down to the stricture.  Afterwards  a still better method was intro-
duced by Sir  Everard  Home, who caused a portion of the nitrate
of silver to be  fixed  within  the extremity of a common  bougie;
which, thus completed, was called an armed bougie.
   A full-sized common bougie is first introduced down to the stric-
ture, and a mark made with the finger-nail on the instrument close to
the  orifice of the urethra.   Thus we  have the measure of the distance
of the stricture from that orifice.   We withdraw this first bougie, and
taking the armed one, which should be of the same size as the common
one previously  introduced, we make a  mark  upon it precisely  at
the  same distance from its point, as  that  already made  on the bou-
gie  employed for the first measurement of the distance of the stric-
ture from the  orifice of the urethra.  We  then  oil it, and  pass  it
quickly along the urethra, until the arrival of the mark at the orifice of 
STRICTURES OF THE URETHRA.
259
the urethra denotes that the caustic has reached the stricture.   The
caustic is then  to be  steadily applied  for a  minute or two  against
the stricture,  and the bougie immediately  afterwards  withdrawn.
This plan is followed up three or four times a week, and each stric-
ture attacked in succession, until the urethra is free.*
   By some judicious and experienced surgeons it  is still maintain-
ed, that this treatment is advisable for spasmodic strictures,  for old
strictures with  spasm, and for peculiarly irritable strictures.   The
following objections,  however, are urged against  the practice by
others,  viz.  hemorrhage—severe  constitutional  disturbance—the
risk of making a false passage—the bringing on of inflammation of
the passage, and retention of urine—swelled testicle, or abscess in
the perinaeum.
   The late Mr. Whately brought forward another mode of treating
strictures with  caustic.   In short, he  boasted  of the  wonderful ef-
fects of  minute atoms of pure caustic  potassa, weighing only one-
seventeenth of a grain.   They were  taken  out of a  bottle  at  the
moment  when  they were wanted,  and  pressed into  a  depression at
the end of the  bougie, and smeared over with cerate.   No  doubt
Mr. Whately cured strictures, but he  did not cure them in the way
he supposed; his bougie, armed with this soapy mixture of fat  and
one-seventeenth of a grain of potash,  would have no caustic effect,
but operated merely on the  principles of pressure and dilatation.
For my  own part,  I  ascribe  much of the  action  of other armed
bougies to the  same principles.
   The employment of caustic has,  for some time, been going grad-
ually out of fashion in this country; and, in  France, the practice
was never adopted to any  great extent.   Ordinary cases do not re-
quire armed bougies; and bad cartilaginous strictures,  attended with
induration, and more  or less extensive contraction and thickening of
the mucous membrane, are manifestly examples, which  the  nitrate
of silver would never relieve.   At the same time,  I believe, that
where a  stricture is  peculiarly irritable,  such irritability may some-
times be more quickly removed with the  nitrate of  silver bougie,
than any other  instrument.
   \owr,  what  is to be  done where all  common plans completely
fail?  Ought we to cut down to the stricture, after having passed an
instrument into the urethra,  as far as the commencement of the ob-
struction, endeavoring next to cut through the diseased portion of
the passage, so as to  find the continuation of it between the stricture
and the bladder, and  then  to convey the catheter into  that organ?
I have seen this operation sometimes done with success; but more
frequently the operator failed to find the continuation of  the urethra.


  * A superior contrivance for the lateral application of the nitrate of  silver to stric-
tures was invented, a few years ago, by 31. Ducamp:  it can be  procured  of Weiss
and Son's, Strand. 
260  DISEASES  OF THE  GENITAL AND URINARY ORGANS.

The difficulty proceeds from the great change and thickening of the
urethra;  and not  only  of that canal itself, but of the cellular mem-
brane and more external parts.   We have to cut into a mass likely
to cause  much perplexity.  At the same time, the point of the staff,
or catheter, is an important guide;  and it is to be remembered, that,
in the generality  of these  cases,  the  membranous portion of the
urethra behind the stricture is considerably  dilated; a circumstance
that ought to facilitate  the detection of it.   I believe  ihe danger of
the operation is overrated, though  not its occasional  difficulty and
frequent  failure.
   Then  another method consists in perforating the stricture with a
stilet, adapted to  a kind of catheter, or tube, out of which it is made
to project after the instrument has been  passed down to the stricture;
an old practice, revived in  modern times.   In  1795  it was intro-
duced again by Dr.  Physic, of the  United States,  who found  it
very successful.   Of late years it has been  practised in  England by
Mr. Stafford and others.  The objections, commonly urged against
this method, are  the  risk of hemorrhage,  and the chance of not
making the perforation  in  the right  direction.   But,  in  obstinate
cases, some risks must, I believe, be encountered;  and this will
happen whether we cut down to a  cartilaginous stricture,  perforate
it through a cannula, or force a conical sound through it.  Mr. Staf-
ford's cases, many of  which he has published, seem  to prove, that
the danger of bleeding has  been exaggerated.  With regard to the
forcible passage of a conical sound through the stricture under ur-
gent circumstances, I  entertain an  unfavorable opinion of the prac-
tice, and  should  be exceedingly reluctant to adopt so uncouth and
unscientific a method,  which  must always  be  attended  with great
danger of producing a false passage.
   [There is still  another mode of  treating  permanent  strictures, as
recommended by  Martial  Dupierris  in  his  excellent  memoir  upon
permanent strictures of the the Urethra.  The method  is entitled the
treatment of strictures by malaxation.  The process  is as follows:—
a bougie is carried through the hard stricture, and  the  instrument  is
retained  as long as the retention  of water  will  permit;  and during
this time, the hard band which  forms  the stricture  is  firmly pressed
by the fingers, or  by compress and bandage,  around  the bougie ;  and
in this way absorption  or malaxation is produced.  The same author
is a strong advocate for dividing the stricture internally.   He has in-
vented some of the most ingenious instruments for the operation, that
I have ever seen.   After he has divided the hard band, he introduces
and retains  a catheter,  and in a short time the stricture is resolved or
removed by the absorbents.
   My own experience  leads me to  apprehend very little  danger from
hemorrhage in the operation, and I  am confident that there are many
cases, in which it  is the preferable  mode of  treatment.—Ed ]
   A false passage, as it is termed, is one caused by  the laceration
of  the mucous membrane of the urethra by the forcible and unskil- 
STRICTURES OF  THE  URETHRA.
261
ful introduction of a bougie, sound, or catheter in a wrong direction.
One consequence  of such  an injury  is, that when an instrument is
afterwards introduced,  the end of it goes into the new passage, and
cannot be made to act  upon the  stricture,  or find its way  into^ the
bladder.   It scarcely  admits of a doubt, I  think, that a false pas-
sage is sometimes  made, and heals up without any inconvenience,
except a degree of hemorrhage at the time of the accident.  In-
deed,  if we were to suspect the occurrence directly  after  it  had
happened,  we should,  perhaps,  give the patient the best chance  of
the laceration healing up without trouble,  by directing him  to retai.i
his water a  few hours, and  then to  pass a catheter of  larger size,
and more curved,  than that which produced the false  passage,  so
that its beak might  be kept close against the upper surface of the
urethra.   I suspect, with Sir Benjamin Brodie, that a false passage
is generally made by  letting the end  of the instrument  press too
much against the lower surface  of the membranous portion  of the
urethra;  though the forcible propulsion of  this part of  the canal  to
one side or the other may lead to  similar  mischief.  However,  by
endeavoring to make the beak of the catheter glide along the upper
surface of the  passage, we elude the lacuna magna, the sinus of the
bulb, the orifices of the prostatic ducts and the sinus pocularis;  all
points in which the end of the instrument  may be entangled, and  all
situated  on  the lower surface of the  canal.
   When a  false passage had been produced in the treatment of a
stricture, Mr.  Hunter  used to introduce a staff as far as it would go,
which he calculated would  generally be to the bottom  of the  new
passage, and of course beyond  the stricture.  The end of  the  in-
strument was then felt for outwardly, and  cut upon.   The  new pas-
sage was next slit open to its  junction  with the urethra,  at a point
beyond  the stricture;  a probe  or director was now  passed in the
direction towards  the glans  penis, and necessarily towards the stric-
ture.  On its further introduction being impeded by the stricture  it-
self, this was cut  through;  and the operation was finished  by with-
drawing  the probe, and introducing  two cannula?, one  through the
wound,  and the other  through the urethra, until they came  together,
when they  were held securely,  a perforator pushed through them,
so as to  divide the obstruction,  and then a bougie,  after which the
tubes were removed.   The operation is now simplified by passing
a catheter directly the structure is divided, which part of the opera-
tion can also be now more  conveniently  done with Mr.  Stafford's
instrument.
   Sometimes profuse  hemorrhage follows the introduction of bougies
or catheters; in such cases, the effect of  cold  lotions on the perin-
aeum,  or, what is  still  better,  the cold bath itself, may be tried.   If
the patient be a strong, robust  subject, we may also have  recourse
to venesection.   In  one instance,  under  the care of Sir  Astley
Cooper, the hemorrhage was  so profuse,  that it was judged neces- 
 262  DISEASES OF THE GENITAL AND URINARY ORGANS.

 sary to divide the artery of the bulb; a measure which had the de-
 sired effect.
   Fistule in Perineo are ulcerated openings in the  perinaeum, which
 are not unfrequently formed in examples of bad strictures, as outlets
 for the  urine, the urethra ulcerating behind the obstruction.   When
 they are about to form, the patient generally experiences an increas-
 ed difficulty of making water; perhaps he is attacked with shivering,
 followed by other  febrile indisposition, and then considerable tender-
 ness  begins to be  felt in the  perinaeum,—a hard tumor, with some
 degree  of oedema,  presenting  itself in that  part, or its vicinity.  The
 skin next inflames, and a fluctuation is felt.  The abscess bursts, or
 is opened, and fetid pus discharged, sometimes blended  with urine
 from the first, and, in other  instances, no urine coming out of the
 aperture till two or three days have elapsed.   The discharge of pus
 then diminishes; but the urine flows out of the new passage in larg-
 er quantities, and whenever the patient makes water, a part of it es-
 capes through  the natural channel, and the rest through the orifice
 of the abscess.   Sometimes instead of one, there  are  several  ex-
 ternal openings produced.
   In consequence  of the urine continuing to flow through the cavity
 of the abscess, the track of the purulent matter becomes lined with
 a texture closely resembling that of mucous membrane, and the ad-
 joining  parts assume a hard  and callous consistence.   Fistulae of the
same  nature may form in the scrotum, in the groin, or even on the
 penis near the pubes.  When the  fistulae in perinaeo are established,
the patient is no longer liable to attacks of retention of urine. Some
 time ago, I had a patient in the Queen's Bench Infirmary who was
 in a  curious state;  for,  in  consequence of the whole of his urine
 having passed for several years through fistulae in the perinaeum, all
 the urethra anterior to their communication with it appeared to have
 been  completely obliterated.
   In  a  few cases, urinary fistulae form a communication between the
 rectum  and the portion of the urethra behind  the stricture; a com-
 plication, the  possibility of which ought to be recollected.   I may
 lay it down as a general  principle, that abscesses in the perinaeum,
 or near the  prostate and  neck of the bladder, should be  opened
 early.   The cure of fistulae in perinaeo must obviously depend upon
 that of  the  strictures themselves; for, in  proportion  as  these give
 way, the urine  resumes its natural course, and the fistulous openings
 heal.   If they should not do  so,  however, we may pass a gum ca-
 theter into the bladder, and confine the patient  for a few days to bed.
 Sometimes, however, when the communication  with the urethra is
unusually large; or when the urine flows  too  freely by the  side of
 the urethra; or when  the catheter excites a great  deal of suppura-
tion in  the passage;  the  foregoing plan will  not  answer.   Under
these circumstances,  let the patient be taught to pass  ihe  catheter
 himself, and let him for some  time never make water without having 
RETENTION  OF URINE.
263
first introduced it, as advised by Sir Benjamin Brodie.   We should
also do another  thing which he particularly recommends, namely,
stimulate the bottom of the fistula with  nitrate  of silver, while we
retard the healing of its orifice by touching it once a week, or once
a fortnight, with the potassa fussa.

                    RETENTION OF  URINE

Should not be confounded with suppression, which  properly means
an interruption of the secretion of that fluid, none being discharged,
because little or none is formed by the kidneys.  Examples of the
latter disorder were commonly noticed in the late epidemic cholera.
  In retention, the urine is poured into  the bladder by the ureters,
but, either owing to the want of power in the bladder, or to an ob-
struction in the urethra, it is not  properly discharged.  Of course,
there is a distension of the  bladder—very perceptible in the  hypo-
gastric  region,—the swelling, indeed, often reaching as high  as the
navel;  attended  with a distinct fluctuation that  can be felt  through
the parietes of the abdomen  as  well as within the rectum.   The
patient  suffers great torture;  there is a hot, dry skin; thirst, an ac-
celerated pulse; and other marks of febrile disturbance.
  The  bladder often continues distended with urine, notwithstand-
ing, the patient may void it at periods in a  stream, and  even pass,
in the twenty-four hours, the quantity usually discharged  by a per-
son in health.   But, then, he discharges merely the overflowings of
the bladder, as it were; and though  the  water may dribble away, or
even occasionally flow out in a stream, that receptacle is never truly
emptied, but remains with an accumulation of urine.   This  is the
retention par regorgement, as it is termed by French surgeons.   In
cases of this  description, serious  mistakes are  apt  to  be made in
practice.  A certain quantity of  urine  is  discharged  from time to
time; a retention is not suspected; and the  patient, of course, does
not receive the benefit of proper treatment.  All surgeons, there-
fore, should remember well these retentions par regorgement, and,
in doubtful cases,  examine the hypogastric  region,  and introduce a
catheter.   This last proceeding can never do harm; it  is fraught
with no peril, not even with  severity; and I can  affirm, from repeat-
ed observation, that it will often be the means, and the only means,
of saving the patient's life.
  The  division of retentions of urine into complete and incomplete,
or total and  partial, appears to me truly practical—a valuable and
well-founded  distinction, well calculated to  put  us upon our  guard
against  taking a wrong view of particular cases.  I  believe, that if
we  examine the hypogastric region, and connect the fulness percep-
tible in  that situation with other symptoms, we  shall rarely be de-
ceived, whether the patient discharge a  part of his urine or not.  If
corpulency should conceal the hard circumscribed  swelling of the 
264  DISEASES OF  THE  GENITAL  AND  URINARY  ORGANS.

bladder, so manifest in thinner persons, we ought of course  to fol-
low the  manifestly prudent rule, which I have laid down for  doubt-
ful cases, and immediately pass a catheter.   In  fat subjects, I would
also recommend the introduction of  a finger into the rectum, where
we may plainly feel the prominence of the distended bladder, and
also a fluctuation,  if, while the finger is applied to the  prominence
within the rectum, we tap briskly on the hypogastric  region with the
fingers of the other hand.  This method, 1 should  say, is particu-
larly useful when the bladder is so thickened and contracted, that it
does not rise above the pubes.
   I constantly inculcate the  maxim of letting the treatment of dis-
eases be always guided, as much as possible, by the consideration
of  their particular causes, the removal of which must of course be
a principal object in view.   Now, retention of urine may depend
upon  a variety of causes, the nature  of which entirely  influences
the prognosis and  treatment; nor  is it possible  to  form any just
opinions, with regard to the treatment of this urgent disorder, with-
out a constant recollection of the different circumstances concerned
in its  production.
   The  general indications are, first, to bring about, if possible, the
discharge of urine through  the natural passage; which  object is
sometimes accomplished by  means of the warm bath, fomentations
applied to the hypogastric region  and perinaeum, bleeding, opium,
hyoscyamus, &c, and  sometimes  by  the  removal of  mechanical
obstacles to  the flow  of  urine; but  still more frequently  by the
skilful use  of catheters.   2dly, When all  these means fail, it be-
comes necessary to  have  recourse to  some operation by which an
outlet is made for the urine.

                          CATHETERS.

   Some are of course designed for the male urethra, and others for
the meatus urinarius.   Another general division of them  is \nto flex-
ible and inflexible ones.  The former, or elastic gum catheters, as they
are usually named, are now brought  to great perfection, being made
of many different sizes, to each of which, a number is assigned. Some
of them are  of such a construction, that they will retain their cur-
vature permanently; while another advantage is their being compos-
ed of materials calculated to  resist, for a long while, the warmth and
moisture of the urethra.   It  is only the best sorts, however, that are
superior in this respect.   They are  provided with stilets and wires,
which give them the requisite degree of firmness, and the particu-
lar  curvature needed  at  the period  when  they are about to be
introduced into the urethra.   Those employed by Sir  Benjamin
Brodie  are furnished with firm iron  stilets,  and flat, broad handles
like those of common sounds, by which means  the surgeon acquires
a greater command over the direction and management of the beak, 
RETENTION  OF URINE.
265
Elastic gum catheters are frequently the only means by which the
lives of patients, laboring under retention  of urine from different
causes, can be saved; and they render this  important  service by
accommodating themselves to the displaced and contracted state of
the urethra, admitting of being passed through a very small channel.
While those of diminutive diameter are frequently the most advan-
tageous for strictures, the larger ones  answer best for  the retention
of urine arising from disease of the prostate gland.  Generally speak-
ing, when  other circumstances are not opposed to it, a large catheT
ther is preferable to one of small size,  as it distends the parietes of
the urethra, and is  much less likely to be obstructed by any of the
irregularities, which the  internal surface of the canal presents at dif-
ferent points of  it.*  Elastic gum catheters may be introduced ei-
ther with or without the  stilet, or, when partly introduced, their cur-
vature may be suddenly  increased  by withdrawing the stilet at the
same  time  that they are  pushed further  into the  passage.   All in-
struments about to be introduced into the urethra, should be smear-
ed with sweat oil or lard.
   Inflexible or silver catheters are introduced in the same way as
a sound or staff, either with the convexity at first towards the pubes,
succeeded by the  tour de  maitre,  or with the concavity of the in-
strument always upwards, that is to say, towards the pubes, or else
with the handle kept in the first instance inclined towards the patient's.
left groin; a plan which Sir Benjamin Brodie follows, and which I of-
ten find advantageous. Whichever mode is followed, the catheter gets
into the same position after its beak has reached the perinaeum,  and
the tour de  maitre has been practised in the first manner of proceeding.
We  have  now to direct its beak through  that point of  the urethra
encircled by the margin  of the opening in the deep perineal fascia;
and, as soon as this is cleared, we should bring the handle of the
catheter gently forwards  and downwards, by which manoeuvre  the
beak will be made to ascend through the  membraneous and prosta-
tic  portions of the urethra into  the bladder.  In this  part of the
operation,  we should  particularly  aim at keeping the  beak of the
catheter against the upper surface of the urethra,  so as to  avoid the
risk of making a false passage.   If the instrument were forcibly and
rudely pushed  towards  the bladder,  without its handle being de-
pressed at  the  proper moment, the canal would certainly be rup-
tured.
   Sometimes the catheter is passed  while the patient is standing
with  his  back against a  bedpost  or the wall.   If he be  in bed, he
should lie evenly,  with  his  knees somewhat raised and  separated.
Mr. Morton's description of the mode of  introducing  the catheter
 * See Th. Morton, on the Surgical Anatomy of the Perinaeum, p. 62. 8 vo. Lond.
1838.
  VOL.  II.                   23 
 266  DISEASES OF  THE GENITAL  AND URINARY ORGANS.

 is perfectly correct.   " The operator, standing upon the left side
 of the bed, takes hold of the penis with  the thumb and fore finger
 of the left hand, and raises it  gently, so as  to efface the curve or
 angle, which  the penis forms,  where  it bends down in front of the
 scrotum.  Holding the catheter in his right hand, lightly poised be-
 tween the thumb and  two first fingers,  the  surgeon introduces its
 point into the orifice of the urethra,  and  continues  to  pass the in-
 strument onwards, until the point reaches the bulb, which is about
 an inch  below the arch of the pubes.  During  this time, the con-
 cavity of the catheter is  directed  towards  the symphysis pubis,
 while the straight portion is held parallel with the front of the abdomen.
 The point of the catheter having reached the bulb, the position of its
 handle is now to be changed from the horizontal direction, in which
 it has hitherto been held  until it  has been brought into a perpendicu-
 lar position, and thus  forms  a right angle with the axis of the pa-
 tient's body.   This movement of the handle of  the catheter will
 cause its point  to  rise out of the sinus  of the bulb, after which it
 may be safely pushed onwards through the  opening in the triangular
 ligament, and thus enter the membranous portion of the canal.   By
 gradually depressing at this time the handle of the catheter, a little
 more between the thighs  of the  patient,  it  will glide smoothly on-
 wards through the remaining portion  of the urethra into the  blad-
 der."*
   The same well-informed surgeon delivers the following valuable
 remarks  on this subject:—" The  natural  obstacles, which  most
 frequently oppose  themselves  io the passage of the  catheter are,
 first, the lacunae of the urethra,  and  the sinus  of  the bulb; after
 which comes  the opening in  the triangular ligament.   When  these
 are passed, the anterior border of the prostate gland, the orifices of
 its ducts, and  the sinus pocularis, may all serve to  obstruct the in-
 troduction of  a  small catheter by entangling its  point; and, lastly,
 the elevated ridge,  which  marks  the commencement of the neck of
 the bladder.   It will be observed, that all these natural obstacles to
 the easy  introduction of a catheter are situated upon the inferior sur-
 face of the  urethra,  and   therefore  they will be  best avoided by
 keeping the point of the catheter gently directed against its superior
 wall.   The margins of the opening in the  triangular ligament will
 not give  any  trouble, if the situation  of  the circular aperture that
 transmits  the urethra is accurately understood: it is nearly one inch
below the arch of the pubes, and equidistant from  the descending
branches of the same bones.  When the  point of the catheter is ar-
rested in either the membranous  or the prostatic portions of the ure-
thra, it will be found of considerable  advantage to introduce the left
 forefinger into the rectum, which will frequently enable the operator
to distinguish the situation, as likewise the  cause of the difficulty, and
* See Morton's Surgical Anatomy of the Perinaeum, p. 62. 
RETENTION  OF URINE.
267
also to direct the instrument  with  greater certainty into  the blad-
der."   Mr.  Morton very properly cautions surgeons against  grasp-
ing the catheter too  firmly,  instead of holding it lightly, like  a pen;
and explains, that if the end  of the catheter be  kept too strictly
against the upper  side of the urethra, it will  be stopped by the su-
perior margin of the opening in the triangular ligament, or, if it pass
that, by  the  edge  of the prostate gland.
   Women are much less subject than the male sex to retention of
urine,  the meatus  urinarius being short and capacious;  not liable  to
stricture; nor to those consequences, which  originate  in  the other
sex from disease of the prostate gland,  and from  abscesses situated
near, and pressing upon, the urethra.*   Neither does the inflamma-
tion, accompanying  severe gonorrhoea  in females,  lead,  as it fre-
quently does in  men, to retention of urine.   Yet women  are now
and then afflicted  with retention of urine,  from causes very differ-
ent from those which bring  it on in  the male sex.   Polypi  of  the
the uterus, or vagina, ovarial dropsy, cancer uteri, displacements of
the womb, especially that  termed retroversion,  and  inflammation
about the neck of the bladder  after parturition, are  the usual  causes
of the disorder  in women.
   The catheter for females is shorter than that  for the male sub-
ject, and has but a slight curve.   It  should be passed without sub-
jecting the patient to exposure: we  should hold the catheter in  the
right hand, and  pass the left forefinger between  the nymphae, and
on the smooth surface  between them,  about three quarters of an
inch below the  clitoris, we  shall readily feel the papilla denoting  the
orifice of the meatus urinarius, into  which we are to direct the in-
strument upwards  with its concavity  kept  forwards.  Here  we
have none  of the  difficulties which  are met  with in  the  male sex
from the length  and  curvature  of the passage, the resistance of  the
deep  perineal  fascia, the yielding of the membranous  part of the
urethra, the impediment formed by the  prostate gland, the  hitching
of the  end  of a small catheter in the orifice of an  enlarged prostatic
duct, or  in the  sinus pocularis of the verumontanum, the  stoppage
of the  beak, of the instrument in the sinus of the bulb, or by  spasm
of muscles in the perinaeum.
  Men advanced  in years  are particularly  liable to  retention of
urine.   This is partly explained by  their being remarkably subject
to disease of the prostate gland, and partly  by the  bladder, after a
certain period of life,  losing some of its irritability and contractile
power so that it no longer retains the capability of lessening its cav-
ity beyond a cerlain  point.   Hence the expulsion  of  urine  in old
persons is  never complete,  a portion of it always remaining in the
bladder after  each evacuation.  At length the infirmity increasing,
  * I have known, however, great difficulty of voiding the urine, and  severe pais,
arise from an abscess of one of the lacunae of the meatus urinaiius. 
268   DISEASES  OF THE  GENITAL AND URINARY ORGANS.

the quantity of urine voided each time  lessens; the desire to empty
the bladder becomes more and more frequent; and, in the end, the
urine only comes away by drops, or in a dribbling stream.
   In this state the sufferings are not very great; the tumor, formed
by the bladder above the pubes, is indolent, and,  if compressed, a
certain  quantify of urine will sometimes flow out of the urethra.
In short, this is a case of incomplete retention; frequently as much
urine being discharged in  the twenty-four hours  as is natural, but
the bladder is never emptied.   However, the symptoms are gene-
rally less urgent than in  other exanples; because this  form of the
complaint does not,  like others,  lead  to a positive interruption or
total suppression  of  the urinary  secretion, nor to a rupture of the
bladder.
   The  weakened  state of the bladder from  age  can  never  be re-
moved; but when there  is a greater tendency than usual to an ac-
cumulation of water, the  use of the catheter should  never be omit-
ted, as  it will afford  immediate relief to the  patient's uneasiness,
and also prevent that degree of distension, which would terminate
in incurable  disease and  total  paralysis  of the bladder, if not in a
rupture of it, and fatal effusion of urine.
   Retention of urine often proceeds from injuries  and diseases of
the spine and pelvis, by which  the bladder is rendered paralytic;
cases remarkable, on account of the strongly  ammoniacal quality of
the urine soon produced  under such circumstances, and the propen-
sity in the coats of the bladder to become softened and ulcerated.
In such cases, the treatment should consist in the regular use of the
catheter, in  cupping the  injured  part of the back, or bleeding the
patient  in the early stage of the  case, followed up by purgatives and
counter-irritation, as blisters, the moxa,  or  an issue.  Fractures of
the spine or  pelvis,  however, would  call  for  particular treatment,
one essential thing in which would  be to keep the injured  bones as
quiet  as possible.
   Another retention of urine, accompanied also by a paralytic state
of the bladder, does not  depend  upon  any  injury of the spine or
pelvis,  but altogether upon  the detrusor urinae muscle having suffer-
ed long and  immoderate distention, in consequence of a  previous
accumulation of urine in the bladder from some other cause.  Here,
whatever benefit  can be rendered, must be derived from the cathe-
ter, tonics,  cold  bathing, the exhibition  of the tincture of canthari-
des, or the tinctura ferri sesquichloridi, and the application of blis-
ters to to the region of the sacrum.
   Retention of urine from inflammation in or near the urethra  is of-
ten exemplified in severe  gonorrhoea, and in acute inflammations
about the prostate gland  and lower portion of the  rectum.  In all
probability,  when some  practitioners  describe a retention  of urine,
as arising from spasm or  irritation, they would be  speaking  more
correctly if they were to refer the disorder principally to the effect of 
RETENTION  OF URINE.
269
inflammation somewhere about the urethra or the neck of the blad-
der.
  When retention of urine proceeds from inflammation in the ure-
thra or neighboring parts,  we should first  try the effect of soothing
antiphlogistic  treatment, antimonial purgative medicines, bleeding,
leeches to the perinaeum, the warm bath, fomentations on  the hypo-
gastric region, and  the effect of hyosciamus or acetate of morphia.
If these means prove unavailing,  the use of the catheter is not  to
be deferred.
  Retention of urine is sometimes caused by the pressure of  collec-
tions of matter on the urethra.   Here the first indication  is to dis-
charge the abscess, and  draw off the  urine.  Afterwards, with the
assistance  of antiphlogistic  treatment,  hyosciamus,  or opium, and
the warm bath, or fomentations,  the patient will soon be able to dis-
charge his water himself.   1 once visited  a case with  Mr.  Holt,
which was attended with a complete and obstinate retention of urine,
arising  from the pressure of an  extraordinary  mass of coagulable
lymph effused in ihe corpus spongiosum, about two inches from the
orifice of the urethra.   The original  complaint  was a virulent gon-
orrhoea, accompanied by chordee.  Here bleeding, the warm bath,
narcotics, the tinctura ferri sesqui-chloridi, and  leeches  to the pe-
rinaeum, did not supersede the necessity for the  catheter.
   Another  retention arises from fungous and carcinomatous diseases
of the bladder.   Cancer  is  sometimes  propagated to  the  bladder
from the rectum  or uterus.   Here the treatment can o.ily be pallia-
tive, and the catheter  is not to be neglected.
   Among the varieties of retention is that depending upon foreign
bodies in the bladder, whether hydatids, coagulated  blood, worms,
or calculi, which may obstruct the passage of urine  from the blad-
der  into  the urethra, or  through  the latter tube.   Here the cure
depends upon  the  removal of the  substances  causing  the obstruc-
tion.  Worms,  hydatids,  and   coagulated  blood  would require
the bladder to be washed out with a syringe  and  catheter of the
largest size.  In cases of worms in  the bladder,  turpentine has great
power in promoting their  discharge;  and, what  is remarkable, gets
into the bladder, in a few seconds  after it is  swallowed.*  Calcu-
li, either in the urethra  or bladder, not above  a certain  size, may
be  removed with the urethral forceps,  sometimes without an inci-
sion in this canal, sometimes with it.
   In children, one kind  of retention is produced by  the diminutive
  * Mr. Law, of Penrith, Cumberland, was kind enough to send me some specimens
of what were supposed to be taenia?, voided from the bladder of a young woman un-
der his care; but if Mr Owen's report be correct, the  patient  must be guilty of de-
ception, as the specimens, which I presented to the College of Surgeons, were found
by him only to be imitations of taeniae,  made from the intestines of some small bird.
From a kind of monomania, she seems to have introduced some thousands of pieces
of these sham txam into her bladder.
                             23* 
270  DISEASES  OF THE  GENITAL  AND  URINARY  ORGANS.

size of the orifice of the prepuce, or a congenital phymosis, as it is
termed.   In such a case,  the  prepuce is  sometimes  distended by
the urine into a large pouch, from which it escapes slowly and diffi-
cultly.  Instances of urgent danger from such a cause are given by
Petit.
   In retention of urine from stricture in the urethra, a difference of
opinion exists about the right  principle  of treatment.   Many  sur-
geons begin with  an  antiphlogistic  soothing plan,  and try the effect
of the warm bath, bleeding, leeches, aperient medicines, or opium,
given by the mouth or in clysters.   Tin's plan may be the  best, if
the retention is quite recent, and the patient is  not in  much agony.
In the opposite case, it is  proper to  resort to the catheter at once.
Thus,  instead of the method adverted to,  Sir  Benjamin Brodie
takes one of the  smallest gum  catheters, which has been  kept for a
considerable time on a curved  iron  wire,  and  which  consequently
will retain its curved form  after the  wire is withdrawn.   He intro-
duces it without the wire,  and  keeps the concavity of the catheter
towards the pubes, elongating the penis at the same time.  The in-
strument will then be likely to  pass the stricture and enter the blad-
der, the urine to  flow out in a  fine  stream, and the patient to be in-
stantly relieved.
   If this plan fail, we may try a small catgut bougie.  We  are to
introduce it as far as we can, and then elongate the urethra by draw-
ing the penis forwards, when the bougie will often  pass.   Certainly,
as Sir Benjamin  Brodie has justly  observed,  it is not  always neces-
sary that it  should pass  into the bladder;  if it enter the stricture,
that is sufficient,—we should then let it remain  there,  until a violent
effort to make water occurs, when  it is  to  be  taken  out,  and the
urine will frequently follow it.
   If this expedient should  not answer, we may take another small
catgut bougie, and bend its point upwards before it  is introduced,
by which means  we shall be enabled to  keep  its point  against the
upper surface of  the urethra, and to avoid the lowrer, where the ob-
struction is  mostly, if not  always,  the greatest.
   When a catgut bougie will not succeed, a silver or an elastic gum
catheter, mounted on a firm iron stilet, will sometimes pass.  When
the stricture is recent, the  catheter should  be of nearly the full size
of  the urethra; but, if the  stricture  is of long  standing, the instru-
ment should be considerably smaller.   Sir Benjamin Brodie prefers
one that is shorter and less curved  than usual; and if  it  is  made of
silver, he advises the tube to be  fixed in a  wooden handle,  which
will enable us to  direct its point more delicately  and  with greater
effect.   If  we use an  elastic gum  catheter, the  iron stilet "should
have a handle, like that of a common sound.   The rules and advice,
given by  Sir Benjamin Brodie on  these matters,  appear  to me par-
ticularly valuable.   We are to pass the  instrument as far as the ob-
struction, and then, having withdrawn it for about  half an  inch, we 
RETENTION OF URINE.                 271
are to pass it on again towards the bladder, keeping the point against
the upper  part of the urethra.    No  violence  is to be employed;
for, if we tear the urethra, we cannot succeed.  I recommend steady
and moderate pressure against the stricture, to be maintained for a
little while, and  then perhaps the  obstruction will begin to relax or
yield, and the instrument  enter it.   If a gum catheter  has been
used, we should leave it in the urethra for a day or two, which will
have a great  effect in curing the stricture.  Even if  we do not suc-
ceed in  getting an instrument into the bladder, the  pressure employ-
ed may  still do good, by  bringing  about a relaxation or  yielding of
the stricture, and on the instrument  being withdrawn, a stream  of
urine may follow it.   Experience  confirms the frequency of such
occurrences, and, if they can be brought  about, the  patient is ex-
tricated  from an urgent  state of danger, as well as from the torture
to which a  retention of urine  from this cause necessarily subjects
him.
   Now, supposing we were not able, in a case of complete reten-
tion of  urine, to relieve  the patient by the  catheter, and he were
strong and  full of blood, he may, in the first  instance, be bled, and
put into the warm bath, and then the catheter tried again;  or, what
is still more  applicable to all  cases, an enema should be  injected,
composed  of 3j.  of tincture  of opium, and Sij.  of mucilage  of
starch,  or gruel—not more, as it would not be retained.   As soon
as the influence of the opium  begins to be felt, if the hypogastric
region be kept  well fomented, sometimes the urine will begin to flow
and, at  all events, there will now  be a greater chance  of success
with the catheter.
   If all the measures specified were to  fail, and the bladder were to
continue distended beyond a certain time, either that organ, or a
portion  of the urethra behind the obstruction in it  would give way,
and the  urine be extravasated in the cellular tissue of the perinaeum
and scrotum.   Thus either a rapid and  fatal inflammation, involving
the peritoneum, would be excited,  or more or  less  extensive ab-
scesses  and gangrene of the cellular tissue of the  scrotum,  perinae-
um, and interior of the  pelvis  be  the consequences.  In  such un-
fortunate cases, the urine does not gravitate to the thigh or nates,
but spreads over the scrotum, penis, the groins, and even higher up
towards the navel and loins.   The reason why  it  does not pass to-
wards the nates is, that it is stopped by the connection of the deep
perineal fascia, with the superficial,  and the rami of the ischium and
ossa pubis.   When  the urethra gives way, there is generally at first
a small  induration in the perinaeum, which is sometimes rapidly con-
verted into a dark, livid, extensive,  and quickly spreading tumor of
the scrotum, groins, and  parts in  the perinaeum.  Nay, sometimes
the effusion of  urine ascends, as I have said,  far  above Poupart's
ligament.   Now, wherever the urine  passes, it is sure to produce
suppuration or gangrene, and sometimes the whole scrotum  sloughs 
272  DISEASES OF  THE GENITAL  AND  URINARY  ORGANS.

away, leaving the testis hanging by the spermatic cords, totally des-
titute of their natural coverings.  The only way of preventing such
evils,—I mean those of effusion of urine,—is to  procure, in some
way or another, an outlet for the urine from the bladder previous to
its rupture, or that of the urethra.
  In stricture,  this may frequently  be accomplished by making an
incision in the membranous portion of the  urethra  behind the
stricture, which part of the canal is  generally dilated into a  sort  of
tumor,  by being  distended with  urine,  forced  thus far by the
bladder.
  In diseases of the prostate gland, attended with urgent circum-
stances, we must either convey the catheter into the bladder, through
the tumor, by a combination of skill and  well-directed  force,  or
puncture the  bladder above the pubes; which last proceeding, how-
ever, is rarely necessary.   I had occasion, however, to adopt it in
one  instance  in University  College Hospital, as will  be mentioned
more particularly when the methods  of puncturing the  bladder are
described.
  But, if urine be already  effused, the surgeon must never forget  to
make free and  deep incisions for its  escape; and, if possible, a ca-
theter should be introduced, so  that the  urine may have a  ready
outlet, and no more  of it pass into the cellular tissue.


                   INCONTINENCE  OF URINE.

  An inability  to  retain the urine in the bladder is of three  kinds:
in one, the water continually dribbles away, without any inclination to
void it, or any sensation of its  being voided.   In other  instances,
the patient can hold  his urine in a certain degree; but the propensity
to evacuate it comes on  so frequently, suddenly, and irresistibly,
that he is compelled to discharge it.   The third kind of incontinence
only occurs when  the patient is asleep.
  The first case depends on a weakness,  or total paralysis, of the
sphincter muscle of the bladder.   As the neck of this organ  is con-
stantly open, every drop of urine escapes into the urethra, immedi-
ately it has  descended from the ureters,  and does not lodge in the
bladder at all.   Sometimes the weakness,  or paralysis,  of the
sphincter is quite a local disorder; but, most frequently, it is  symp-
tomatic of some other affection.  In  the first case,  it is often the
consequence of a  difficult labor, in which the neck  of the  bladder
has  been a long while  compressed;  or of the formation of fistulous
communications between the vagina  and  the bladder.   Sometimes,
incontinence of urine depends on a malformation of the urinary pas-
sages, and exists  from the time of  birth.   The complaint is often
an effect of apoplexy, injuries and  diseases of the spine, &c.
   It is not dangerous,  though exceedingly annoying, in consequence 
INCONTINENCE OF URINE.
273
of its continually wetting the clothes, causing  a disagreeable smell,
and even excoriating the parts over which the urine flows.
   When the complaint is local, tonics and astringents are indicated;
and the  principal  remedies are,  cold  bathing, bark, blistering the
sacrum or  perinaeum, the  tinctura cantharidum,  the shower-bath,
electricity, and rubbing  the spine  and  sacrum with stimulating lini-
ments.
   When incontinence of urine is  merely the  effect of another dis-
order, the  latter claims the principal attention.
   The second species of incontinence  of urine is of a spasmodic
nature, and commonly depends on some irritation operating  on the
bladder.   Hence,  the indication is to find out the irritation, and  if
possible to remove it.  Hemorrhoidal complaints, suppressed metres,
a stone in  the bladder, a fistula inano, &c, may cause the affection.
When the  particular irritation  cannot be discovered, general  sooth-
ing and antispasmodic remedies, such as bleeding,  opium, the warm
bath,  fomentations,  &c,  should  be prescribed.   The uva ursi  is
sometimes useful, of which a  scruple,  or half a  drachm, may be
given three times a day.
   This kind of incontinence of urine is frequently only a symptom
of epilepsy, or hysteria.   Sometimes  it  originates  from  pressure
made upon the bladder;  and hence, it may be a symptom of polypi
of the uterus, a prolapsus of this  viscus, or  difficult parturition.*
   The last case is that, in which  the urine is involuntarily discharg-
ed in the night-time, when the patient is asleep.   The  infirmity  is
mostly  met with in young boys and girls;  and, for the  most part,
spontaneously  goes  off as they approach the adult  state.   They
should avoid drinking any fluid just before going to bed, and empty
the bladder before they go to sleep.
   When,  in adult persons the complaint does not yield to the above
precautions, one fourth of a grain of the powder of cantharides, given
with milk of almonds, every evening, has been known to be of ser-
vice. The  effect of exhibiting a grain of opium, or two grains of ipeca-
cuanha, every night, a little before bedtime,  may also  be  tried.  The
best apparatus  for catching the urine, where  no cure can be accom-
plished, which I have ever seen, consists of a  long tube, made of elas-
tic gum, or other flexible water-proof material, and capable of hold-
ing about a pint and  a half of fluid.   It causes little inconvenience,


  * Retention of urine, from  paralysis of the bladder,  is a case attended with an in-
voluntary dribbling away of this fluid, if the catheter be not properly employed, and
is a disorder that has frequently been  mistaken for an incontinence of urine.  As soon
as the bladder is distended to a certain degree, the urethra being  i>nobstrurwd, the
continued sect et ion from the kidneys, instead of causing) the  bladder  to give way,
p isses off through the natural channel.  The discharge of urine leads the unwary sur-
geon never to suspect the real nature  of the disease; but if a catheter chance to bu
introduced, the quantity of urine druwn off immediately throws light upon the true
character of  the disorder. 
 274   DISEASES  OF  THE  GENITAL AND URINARY ORGANS.

 and, as it is so narrow as to be concealed by the trowsers, it occa-
 sions no disfigurement.
   There is a particular incontinence of urine, arising from the for-
 mation of a  preternatural communication  between the bladder and
 vagina.   It is usually the consequeuce of a slough, and  sometimes
 follows difficult labors.   The continual dribbling of the urine through
 the opening, generally prevents it from healing; but by making the
 patient lie a good deal on her abdomen, the water is hindered  from
 constantly escaping, and  the  aperture will  sometimes heal.   The
 fistulous  opening may occasionally be made to heal up, by scarifying
 its edges, and  keeping them afterwards in contact with the twisted
 suture; the  patient  being made to lie on her abdomen, as much as
 possible, for tw7o or three days.   In the worst cases which admit of
 any chance of relief, perhaps, the actual cautery, applied with  great
 caution  and  moderation, is what ought to  be employed.   Many
 cases on record attest its frequent efficacy.
              ]
                          GONORRHOEA,

 Or Clap, may be defined to be an inflammation of the mucous mem-
 brane of the urethra, attended with a discharge of puiiform matter,
 which  is  frequently  believed  to be .of a specific quality, and which
 is well known to possess infectious properties.   In  women, the dis-
 charge takes place from the mucous membrane of the vagina, labia,
 nymphae, and clitoris, as well as from the lining of the meatus urina-
 rius, and, according to M. Ricord, sometimes also from the  lining
 of the uterus itself.
   A gonorrhoea is found to begin at an earlier period after infection
 than a  chancre, generally within a week or ten  days.   However,
 some individuals are attacked  in two or three days; and  others ex-
 perience  no  inconvenience, perhaps, for two or three weeks.   The
 earliest symptom is  an itching  at  the orifice of the urethra, some-
times extending over the whole of the glans penis, which, with the
 mouth  of that canal, has a fuller and  redder appearance than usual.
 The glans being reddened and smoothed by distention, is sometimes
 compared to a ripe cherry.   The natural secretion of the mucous
 membrane of the urethra first loses its  viscid quality, and becomes
 thinner, but soon assumes a thicker consistence, turning white, yel-
 low, or greenish, so as to have the common appearances of  pus.
  About the period when the discharge begins, heat and pain are
 experienced in the passage, more especially at  the  time of making
water.    The urine  passes with a  scalding sensation, and sometimes
with considerable difficulty, either in a'very diminished, brokenstream,
or merely by drops.   Occasionally, the irritation is such, that a com-
plete retention  is brought on.   In ordinary cases,  the  inflamma-
tion does not extend further along the urethra than an inch and a half, 
GONORRHOEA.
275
or two inches, from the orifice—the specific extent, as it was termed
by Mr. Hunter; but, in  severe examples, the  inflammation  passes
through the whole course of the urethra, and even affects the mu-
cous membrane of the bladder.  When this happens, the patient's
sufferings are considerably aggravated, the pain about the hypogas-
tric region,  perinaeum, and hips,  being particularly distressing.   In
such cases,  small indurations, consisting of enlarged glands, may of-
ten be  felt  in the course  of the urethra,  and sometimes these,  and
Cowper's glands  inflame and suppurate.
  In general a common  clap increases,  or, at all events,  maintains
itself in an unabated degree, lor ten days or a fortnight: the discharge
then frequently begins to lessen; the pain and scalding  sensation in
making water to subside; and in a month or six weeks, none of the
symptoms may remain.   In this manner, gonorrhoea may undergo
a spontaneous cure.   Sometimes, however, the acute symptoms go
off, especially  the pain  and heat  in making  water; the quantity of
discharge is also reduced; but the urethra, instead of resuming its
natural healthy  mucous  secretion,  pours out a thin, colorless, or
light green matter, which may continue for a long time to ooze from
the passage, constituting what is called a gleet.
  It was one of the opinions of John Hunter, that a gleet is  essen-
tially different, from a  gonorrhoea, in not being infectious, and in con-
sisting of a  discbarge  composed of globules, blended with the mu-
coids secretion of the part; while the matter of gonorrhoea is made
up of globules blended with a serous fluid.   Gonorrhoea in its worst
forms is truly a distressing disorder.   Not only may the inflamma-
tion run along the urethra to the bladder itself, as already described,
but fibrine may be effused in the corpus spongiosum urethra, so that,
when an erection Likes place, one side of the penis being less yield-
ing than the others, the part assumes a distorted or hent appearance,
termed chordee,  and  attended with great suffering.   The  irritation,
accompanying gonorrhoea,  gives a tendency to erections; which are
perhaps a source of  far greater suffering, especially when combined
with chordee, than the ardor urinae, or even the irritable state of the
bladder itself.
  Frequently, the inflammation extends to the  prepuce, which be-
comes thickened, swollen, and  (Edematous, so that the glans cannot
be uncovered; a state termed phimosis.
  Sometimes other parts are affected, as the glands in the groin, and
the  testicle, which  are  attacked by acute inflammation.   Hence
sympathetic  buboes, and the inflammatory painful enlargement of the
testicle, absurdly  called hernia humoralis.   I may say, that tender-
ness of the  glands in  the groin,  and of the testicles, is  an ordinary
attendant on clap, so  that even  when one of the latter  organs does
not actually inflame, it is often  in a state in which the use of  a sus-
pensory bandage affords  much  comfort. 
276   DISEASES  OF THE  GENITAL AND URINARY ORGANS.

   Several curious and interesting questions necessarily present them-
selves to our notice in the  consideration of gonorrhoea.
   The first is, whether a  clap depends upon a specific virus?   All
surgeons know that simple  irritation of the mucous membrane of the
urethra will increase the quantity,  and alter the quality, of its natur-
al secretion, or will change the mucous secretion  into one of pus,
so as to bring on a discharge.   Some practitioners  denominate  a
case of this description a simple or benign gonorrhea, reserving the
epithet virulent or venereal for the case which is conceived to de-
pend upon a specific poison.
   A discharge of matter from the urethra may result from any kind
of irritation affecting it, as that of the employment of bougies,  or
of the application of various acrid and unhealthy  secretions to  its
orifice in the act of coition.   Such altered secretions may be form-
ed from the mucous surfaces of the female  parts of generation, to-
tally unconnected with  the poison  of  syphilis.  What experienced
surgeon does  not know, that  when female children are violated,  a
discharge generally follows,  in consequence of the injury done  to
the parts, even though  there may be  no actual laceration of them?
And hence the offender is frequently alleged to have been in a state
of disease when  he perpetrated the  crime,  though  this  inference
is far from being warranted, merely because  the  female is attacked
with a discharge.
   But, besides these  gonorrhoeas  from simple irritation, it  is con-
tended that there are others, arising from the influence of a speci-
fic poison, and, as  some surgeons maintain, from  the identical poi-
son  that  is concerned in producing the venereal disease.
   As we know not what the poison of gonorrhoea  is, nor what the
syphilitic  poison  itself is in a separate state;  nor  even whether  there
may not be, as Mr. Carmichael conceives, several varieties  of ven-
ereal poison,  theidetermination of this question  is particularly dif-
ficult.   If we were to  judge of the nature of the venereal and gon-
orrhoeal poisons by their general effects, and  consequences of each
of them,  we should be led to the inference  that they are certainly
not  identical.   We  see in  gonorrhoea, generally speaking, only a
discharge from the  mucous membrane of the urethra without ulcer-
ation, going through a  certain course, and usually terminating  of it-
self in  three,  or four, or five weeks,  without  any eruption, sore
throat, or  affections of the bones.   In syphilis we  see a  disease
that begins with  ulceration of another texture,  generally lasts con-
siderably longer than a clap, and  is disposed to  bring on a  train of
secondary symptoms,  denoting its  influence over the constitution at
large, and often lasting for several months.
   The arguments,  in support of the  identity of the two poisons, are
of the following kind:—
   1st. The supposed  conveyance of the venereal disease  from a 
GONORRHOEA.
277
country where it was known to be prevalent, to a very distant one,
in which it then commenced for the first time.   Now, Mr.  Hunter
supposed that it could  only have  been conveyed, during a voyage
of several months, in the form of gonorrhoea, as he thought  that a
chancre on the penis would in this time have destroyed the organ.
   2d.  The occurrence of secondary symptoms after gonorrhoea.
Mr. Hunter mentions a gentleman who had gonorrhoea three times,
which  was treated without  mercury:  about two months after each
infection, he  had secondary symptoms, which consisted of  ulcers
in the  throat, and blotches on the skin.
   3d.  The result of an inoculation  with  gonorrhoeal matter,  as
performed by Mr. Hunter himself; followed  by bubo, u^er on the
tonsils,  and  blotches  on  the skin;  all ultimately  cured  by  mer-
 cury.
   If the particulars of this case  be  closely attended  to, it will  be
 perceived that Mr. Hunter deviates  from some of his common doc-
 trines  about the venereal disease.  In the first place, the  primary
 sores, resulting from the  inoculations, he says, healed up without
 mercury; then the  sore throat, after  having  been made  to heal by
 mercury, broke out afresh, and required this medicine again.   Now,
 if Mr. Hunter had not been intent on  proving  the identity  of the
 gonorrhoeal and syphilitic  poisons, he probably would not have ad-
 mitted,  that a primary sore  could  have healed without  mercury,
 or that  a  secondary  one, after  being  healed,  could have  broken
 out again, without a  new  stock of infection; for these  are the
 principles which   he  insists  upon   in  other  parts  of  his  work,
 though, inasmuch as they are not correct, they  do  not really affect
 the inference deduced from the present case by  Mr. Hunter,  except
 by  proving  that this  great man had  no settled rules for  deciding
 whether a complaint was  venereal  or not.
    4lh.  The  frequent production of secondary symptoms,  when
 gonorrhoea leads to ulceration at the orifice of,  or within, the urethra.
  According to the researches of  M.   Ricord with the speculum va-
 ginae, and his  experiments  with inoculation, ulceration  or  a true
 chancre in the vagina, or other concealed situation, is a much more
  common accompaniment of gonorrhoea in women than usually sup-
  posed;  and  he declares that syphilis is only inoculable with the dis-
  charge, and secondary symptoms liable to follow gonorrhoea, when
  such  ulceration exists.  As this is asserted by him to be the  fact,
  with respect to women, he deems the inference  warrantable, that the
  same combination of  a discharge from the male urethra with a true
  chancre in that passage, is also not uncommon, and will serve to ac-
  count for the very opposite doctrines frequently entertained respect-
  ing the dependence of gonorrhoea and syphilis upon the same  poison.
  The  fossa naviculars in men is  found by M. Ricord to  be the part
  of the urethra in which a primary venereal ulcer  is  oftener found,
     vol. n.                  24 
278   DISEASES  OF THE GENITAL AND URINARY  ORGANS.

than  any other portion of the urethra.  Every experienced surgeon
must have seen chancres occupying the very mouth of this canal.
  If these facts be admitted, the plain inference from them is, not
that poisons of gonorrhoea and  syphilis are identical,  but  that the
former is a decidedly different  disease, and that, unless a chancre
exist in the urethra, no  discharge from this passage, no mere gon-
orrhoea, can be the source of secondary symptoms.
  While some surgeons observe no  particular  differences between
these comparatively rare secondary symptoms of gonorrhoea and the
more frequent ones of syphilis, other practitioners  have attempted
minutely to  define such  differences, more especially  Mr. Carmi-
cheal,  who, as we know, attributes to gonorrhaea papular eruptions,
soreness of the fauces, pains in the larger joints, iritis, and inflam-
matory swellings over the superficial bones.
  Sometimes, though the doctrine of gonorrhoea  originating  from
any specific poison is rejected, it is conceived, that the disease may
arise from the operation of any  mechanical  or  chemical  stimulus,
and that, in this way, infectious matter  may  be generated,  which
will even propagate, under certain circumstances, syphilitic as well
as gonorrhoeal complaints.   This view seems to combine two things,
namely,  a  denial of the  existence  of a  specific gonorrhoeal  virus,
and the admission that gonorrhoea may, if it lead to ulceration, give
rise to syphilis itself.   It is sometimes imagined that this hypothesis
rather  coincides with many of the anomalies  in the history of the
veneral disease, especially the probability  of the infinite multiplicity of
its origin in every country where promiscuous sexual intercourse pre-
vails to a great extent; and that  it tends to reconcile  some  of those
extraordinary relations, in which  soldiers, having intercourse with the
same woman in quick succession, severally contract gonorrhoea,chan-
cre, or primary sores of various characters, all from the same source
of infection^ a subject already discussed in the observations on syphi-
lis.   For my own part, I feel less  difficulty in  adopting the conclu-
sions to which M. Ricord has been brought by  his experiments with
inoculation and the speculum.
  The arguments against the identity of the gonorrheal and vene-
real poisons are:—
  1st.  The rarity of secondary  symptoms after gonorrhoea, and the
frequency of them after a primary venereal sore.
  2d.  The differences  between the secondary  symptoms of each
disease, when such symptoms do occur.
  3d.  If the poison were  the same in each  case,  why should
the matter of gonorrhoea not commonly  produce  chancres on the
glans and prepuce, with  which parts it is so  much  and so long
in contact?
  4th.  Why should it be a disease completely beyond the control
and influence of mercury?
  5th.  If the application of the poison to a  secreting or mucous 
GONORRHOEA.
279;
surface be specified in explanation of the difference of effect, why
does the syphilitic poison frequently produce chancres on the secret*
ing surface of the corona  glandis, and, occasionally, notwithstand-
ing all assertion  to tho contrary, within the  urethra itself? and  why
should women ever have chancre at a!?, as the poison in them must
generally be applied to a mucous surface?
   It is not an uncommon belief, that the various degrees of severi-
ty, which a gonorrhoea assumes, indicate only the stage and extent of
the inflammation,  which, wherever the natural susceptibility exists,
is excited by the introduction of any irritating secretion.
   It may here be remarked, that all this is  true: yet, we find  that
persons have chancres secreting pus close to the orifice of the ure-
thra, without gonorrhoea being brought on by it.  This is certainly
another fact, and what does it tend  to prove?   Not, that  the two
diseases  depend  upon the same virus, but, merely that the matter of
chancre  will not commonly irritate the urethra of the individual hav-
ing such a sore upon the penis.  Neither does it generally cause ul-
ceration  and chancre  on  the neighboring part of the  penis.   So
far as the fact proves any thing on this question, it is,  I think, de-
cidedly against the conclusion, that these two diseases depend upon'
the same kind of virus.

                 TREATMENT OF  GONORRHOEA.

   Notwithstanding  our ample  experience in the treatment of clap,,
we are quite  ignorant of any specific remedy for it.  The disease,
however, though characterised by a disposition to go on for three or
four weeks (whatever be done), is capable of being rendered much
milder by proper treatment, and also of being prevented from con-
tinuing for many weeks, and  even  months,  in  the form of gleet.
The benefit, therefore, which a patient with  gonorrhoea may derive
from surgery is not unimportant.
   Gonorrhoea is  manifestly  attended  with  inflammation  of  the
mucous membrane of the  urethra, as indicated by  the  heat,  pain,
and swelling, and often by the effusion of fibrine in the corpus spon-
giosum,  and  other effects.  Its  first  stage should,  therefore, be
treated on  antiphlogistic  principles; the  penis should be  covered1
with linen wet with cold water or the lead lotion;—or, as  preferred;
by  M. Ricord, the penis, scrotum,  and perinaeum may be foment-
ed with a decoction of poppy-heads,  to which, when  the pain is=
severe, laudanum may be added.  Or the same parts may be foment-
ed with a decoction of the leaves of belladonna.  The patient should
abstain from  violent exercise, wine,  full diet,  and high  seasoned-
dishes, and take   purgative medicine  every   second or third  day.
When the discharge is  quite incipient, M.  Ricord finds the applica-
tion of from twenty to forty leeches  on the perinaeum, according to»
the strength s£ the patient, and the exhibition of copaiba, or cubebs-, 
280 DISEASES  OF THE  GENITAL AND URINARY ORGANS.

the most  successful mode of  checking the complaint.  But,  he
considers  the latter medicines, after a gonorrhoea is completly de-
veloped, as inefficient, and calculated to render the digestive organs
averse to  their exhibition  in a later stage, when they may become
necessary.*   The urine is to be rendered less  stimulant,  by giving
mucilaginous  diluent  drink, as  barley water, linseed tea, or a solu-
tion of gum arabic, with a proportion of nitrate of potash and a little
syrup of poppies in it.  The liquor potassae may be given in doses
of ten drops,  repeated eight or ten times  in the course of the day;
for it has the  effect of rendering  the urine  less  irritating.   Medi-
cines, calculated to promote the secretions  in  general, to keep the
bowels open and the  skin  moist, are generally approved of in the
early stage; as mixtures containing the liquor ammon.  acet. and ni-
trate of potash,  or powders composed of the nitrate of potash, and
a small proportion of pulv. ipec. comp.   The decoct, hordei comp.,
with nitrate of potash, and tinct. hyosciami, is a medicine very com-
monly prescribed.
   When, from the violence of the pain about  the bladder and per-
inaeum, there is reason to believe, that the inflammation  extends fur-
ther than  usual, or when the  urine cannot be voided without the
utmost difficulty, or is even retained altogether, the treatment must
be still  more  active;  leeches should  then invariably be applied  to
the perinaeum, venesection practised, the  slipper-bath employed,
the bowels freely and repeatedly opened, and the patient kept under
the moderate  influence of  opium,  or  hyosciamus, with the view of
lessening  the  spasm at the neck of the bladder.  If complete  re-
tention come  on, a clyster, made  with two or three ounces  of the
mucilage  of starch and from  forty to sixty minims of laudanum,
should follow  bleeding and the  warm bath.
   After the inflammatory stage is over, and the discharge and some
uneasiness about the  passage are the chief inconveniences left, the
indication is to  employ means  calculated to bring the secretion of
the mucous membrane into its natural state again.   For this purpose,
we may direct the patient to take certain  medicines, which act upon
the membrane of the urethra by altering the qualities of the urine,  as
he balsam of copaiba, or cubebs: twenty drops of the copaibat
balsam may be taken three times  a day, in a glass of  milk or pep-
permint-water, or it may be made into draughts  with  the  mucilage
of gum arabic and  a little of the  aqua pimento.   The cubebs, or
Java pepper, is to be given in doses of 3j. or 3ij. twice or thrice
a  day, or we may employ injections, which  may either be of an
astringent or  stimulating kind.   The former generally consists of a
solution of the sulphate of zinc, or of the acetate of lead in water,
or rose-water, in the proportion of ten or twelve grains to six ounces
of the fluid.  The stimulating injections usually contain the bichlo-
* Ph. Ricord, Maladies Vener. p. 707—712. 
SOTTORRHCEA.
28B
fide of mercury, or nitrate of silver.   Two grains of the bichloride
in six ounces of distilled water make a strong injection, and  about
five  grains of the nitrate  of silver; though this has been of late
sometimes used in the proportion of ten grains to an ounce for the
stoppage of the discharge in the chronic  stage.  When the  first
periods of a gonorrhoea  are attended with pain, I think with M.
Ricord,  that,  though  astringent,  stimulating,  or other  injections
sometimes  stop the discharge, they mostly fail, and  do more harm
than good.   But, should  the discharge commence without pain, or
other sign of inflammation, the balsam  of copaiba, or the powder of
cubebs, might  be tried, with  the view of putting a sudden stop to
the complaint;  but all bleeding is unnecessary.   With the same ob-
ject,  M.  Ricord  has a  good opinion of  the  efficacy  of drastic
purges; and joins many other surgeons in  commending the trial of
nitrate of silver injections; but, instead of beginning with one com-
posed  of ten grains  to each  ounce of water, as recommended by
some modern surgeons, he prefers commencing with only a quarter'
of a grain to that quantity of water, and augmenting the strength of
the injection by degrees.*  I believe with  M.  Ricord,  and  many
others, that, so long as there is a good deal of inflammation,  it  is
best not  to employ any kind  of injection.
   The erections, which occur in the acute stage  of  gonorrhoea, are
the cause of great suffering.   The best means for their prevention,
or relief, consist in not letting the patient  have too many blankets
on his bed, or  be in too warm a chamber; in applying cold  water,
or evaporating  lotions to  the parts; and  in prescribing the tinct.
hyosciami, vinum colchici, or, what M. Ricord joins in the praise1
of, camphor combined with opium, and given either in the form of
pills, or that of an enema.
   For the  stoppage of profuse bleeding from the  urethra, caused by
laceration of the urethra during an erection, the following plans are
recommended:—ice-cold  water  to  the penis,  inner  side of the
thighs, perinaeum, and hypogastric region; acidulated beverages, not
however taken  too freely; an elevated position  of  the pelvis; not
heating the patient with  too  many coverings on his bed;, a towel
rolled  up, and  kept firmly pressed  on  the perinaeum with a  T  ban-
dage;  or circular compression of the corpus spongiosum.  If these
means prove unavailing, M.  Ricord introduces a catheter, so as to
compress the urethra from within outwards for a day or  two, com-
bining with it sometimes very moderate external  pressure.f   When
gonorrhoea is  productive of dysury, leeches should be put on the
perinaeum,  blood taken from the arm,  the  warm bath used, and, as
M. Ricord directs, the extract  of belladonna rubbed on the  perin-
aeum.  But, when  urgent retention of urine prevails, a  catheter is..


         • Op. cit. p. 711.                     t Op. cit. p. 716.

                             24* 
282   DISEASES  OF THE  GENITAL AND  URINARY ORGANS.

to be introduced, No.  8. or 10., which will  pass more readily than
a smaller.   In France, the instrument is sometimes smeared with an
ointment containing a  proportion  of the  extract of belladonna*; a
method which may be  more  deserving  of attention than it has  yet
been deemed in this country.

                    TREATMENT OF  GLEET.

   We  may try injections of bichloride of mercury, or nitrate of
silver, or the  internal  exhibition of  balsamum copaibae, cubebs,  the
tinct. ferri sesqui-chloridi, or tinct.  of cantharides, in doses  of  ten
Or fifteen drops thrice  a day;  and in particular obstinate cases,  the
cold  bath, sea-bathing, rough  horse exercise, a blister  under  the
urethra, bark, sulphate of  quinine, and steel medicines.
   Many gleets cannot be cured by any of the preceding measures,
because the  disease may not be  simply a wrong  action of the  se-
creting vessels of the urethra, but dependent upon other diseases of
that canal, or parts connected with it, as is exemplified in stricture
and disease of the prostate gland.   Hence, when a  person applies
to me for a gleet, and  says that be has had it a long time,  I gener-
ally  make it a rule to pass a  bougie, in  order to ascertain whether
there is any other disease of the passage.

                      [irritable urethra.

   There  is another  subject pertaining to the  urethra, which Mr.
Cooper seems to have passed over, and which is one of very conside-
rable moment; I  refer  to the irritable urethra.   This disease is met
with generally in young subjects, though  I  have seen  it in men who
were  forty.  The most common  cause of the disease is self-pollution,
though sometimes too much venereal indulgence gives rise to it.  One
of the most indomitable cases 1 have ever met with, was in a gentle-
man aged about forty, who  possessed  a robust  constitution, and who
from  early life, had  been excessive  in  his  indulgence with  women.
He was married and had several children.  When he consulted me,
he could  not  obtain an erection, the semen flowed involuntarily, and
was found commingled with the urine.
   This sad disease occurs most often in young men of sedentary hab-
its, of the sanguineo-nervous temperament,  and  of  correct moral
training ; who, while they shudder at  the idea of debauchery, frequent-
ly fall into the sad habit of Onanism, and thus  induce the  disease of
which we are  speaking.   A stricture, situated anterior  to the  caput
gallinaginis,  is another cause of irritation  in the prostatic portion of
the urethra.
   The symptoms are frequent involuntary emissions, while in a rest-
less dreamy sleep, or they may occur daring the day while the patient
is walking, or while at stool.
* Ricord, Mai. Vener, p. 718. 
IRRITABLE URETHRA.
283
  The bowels are usually constipated.  Lallemand cites or>e case in
which the patient had no  alvine dejection for forty days.  The geni-
tals are soft, flabby and  small, often emitting either  a seminal  or
garlic like odor; the testicles are often small and at times extremely
sensitive.   The appetite is capacious, the digestion imperfect, and the
secretions of the alimentary canal and its collateral  viscera are much
diminished; hence the severe constipation.  The renal discharge va-
ries much in quantity and quality.   Often, after a seminal discharge,
the kidneys secrete very  profusely, a pale, limpid fluid,  accompanied
by a dull oppressive pain  in ihe loins.   The circulatory apparatus is
often  far from a normal condition ;  the pulse  is too rapid, small  and
feeble;  ihe patient is greatly annoyed by palpitation of the heart, the
extremities are cool, lh6  capillary circulation  is feeble,  on which ac-
count the surface is livid, and covered with a cold clammy sweat.
  The respiration is often hurried and  irregular.  The  principal de-
vastation is manifested in  the nervous system.  The patient complains
of great bodily weakness,  the  limbs  totter, and the hands tremble;
the mind, once manly and full of high promise,  becomes  impotent,
and shrinks from every  effort ;  the  poor victim avoids  society, loves
solitude, and the companionship of his own wretched  and  polluted
musings, be dreads the approach of every  human  being,  and never
ventures to look any one  full in the face.   The downcast look,  the
shamefacedness and the  dark  gloom  which  overhangs the  counte-
nance, the tremulous lip, and the weeping eye, are unerring exponents
of the frightful malady which has ruined mind and body, and not un-
frequently epilepsy or insanity  follow in the result.
  The most unequivocal symptom of the disease, is discovered on the
introduction of a metallic bougie, for when  the point of the instru-
ment  reaches  the prostatic portion of the urethra, the  pain is often
intolerable, and the  spasmodic contraction of the surrounding  mus-
cles, renders the passage of the bougie  impossible, until  after the ad-
ministration of a large anodyne.
  The pathological anatomy in this disease, consists in  a soft, thick-
ened, and vascular state, of the prostatic portion of the  urethra;  the
caput gallinaginis is enlarged, the ductus  ejaculatorii patulous, often
ragged or fissured  for two or three lines, and  the diameter  of these
tubes sometimes attains the enormous size of a crowquill.   The  vasa
deferentia  in severe cases are enlarged throughout, and  involved  in
the disease.  The epididymi are either enlarged  and tender, or  soft,
and the didymi are atrophied.  The prostate gland is hypertrophied,
and often very sensitive.   The vesiculae seminales are  filled with a
morbid secretion, which is either mucus,  pus, or a concrete  tubercu-
lous like matter.   The urinary apparatus  is often deeply involved  in
the irritation.   Sometimes  the mucous membrane of the bladder se-
cretes a transparent, and sometimes an opaque viscid mucus, which
is  liable in such  cases to   be confounded  with  the watery semen.
The ureters and kidneys share  largely in  the  morbid sympathy ;  the
latter are at times found hypertrophied, or they are atrophied, or  they
are filled with small abscesses.  When the  genital organs are feeble,
and inclined to be irritable, there is often a copious secretion  of urine 
284  DISEASES OF  THE GENITAL AND URINARY  ORGANS.

after the emission, because of the irritation communicated to the kid-
neys, from the ductus ejaculatorii and cervix resicae ; similar to what
we  see happen in cholera morbus, when some crude substance irritates
the ductus communis choledocus.
  Effusions  are often  produced' in  the  great cavities : the brain  is
softened, or  becomes  apoplectic, and the vertebral column becomes
diseased.
  The diagnosis is easy, when the investigation is  thorough, especial-
ly if the bougie is introduced.
  The prognosis, when the disease has not too far invaded the gene-
ral  system, and there is no positive disorganization, is  rather favora-
ble  : but when disorganization  has taken place, then we are to expect
impotency both of body  and  mind.  The patient suffers from  all
kinds of symptoms, and at length becomes a  confirmed lunatic or an
idiot.
  The treatment in  these  cases of  irritable  urethra  is such as will
tend to remove the exciting causes and to invigorate the general sys-
tem. The patient should be compelled to desist from bis solitary habits,
and made to mingle  in society.  A sedentary mode of life, should be
exchanged for one which requires labor and muscular  exertion.  Ev-
ery thing  which tends to  inflame the imagination must  be avoided.
The patient must sleep in  a cool room, on a  hard  bed, have but few
clothes over the genital organs, while the lower extremities as well as
the upper must be kept warm.   He must bathe the genitals and  loins
in cold water, night and morning, and the best mode of application-
is by the  shower bath, or  douche, after which active friction  should
be employed.  Cold  water  injected into the rectum is also serviceable.
  The diet should be strictly vegetable in most cases, and the patient
must not be permitted to eat  after three or  four P. M.,  in order that
the stomach may be quiet after  going to bed, and that the rest  may be
undisturbed  by dreams.  There is a  tendency to constipation in these
cases, which must be  ovorcome by the use  of mild laxatives
  As a tonic, I have never found any preparation  so efficient,  as the
muriated  tincture of iron.  Instead of the above,  I have often found
much advantage from  the  use  of the extract of nux  vomica.  Sul-
phate of iron and aloes made into a pill, and given  four times in twen-
ty-four hours.
  I attach much weight to the  local  treatment : this  consists  in  the
use of a metallic bougie, every other day,  until  the urethra becomes
somewhat tolerant of  its presence, and then in carrying  the solid  ni-
trate of silver, into the prostatic  portion of the urethra,  by means of
a porte au camtigue: it should  not  be allowed to remain longer, than
from half a  minute  to  a minute.  There  is  considerable pain for  a
time, and ardor urinae when the patient passes his   water,  but  these
symptoms soon subside, the emissions cease, and he begins to  recover
his  strength  of body and his spirits.
  It is often  necessary to repeat the operation three or four times, and
I have met with cases, in which the caustic has availed nothing,
though these were not, properly speaking,  cases of irritable urethra,.
for  there  was little  or no pain when the  bougie was  introduced- 
SYMPATHETIC
BUBO.
285
When the presence of the bougie in the urethra causes pain, I regard
the case as a good one for the caustic.
  The mucous membrane of the diseased  part of the urethra, is at
times thickened and fungous, and is easily torn by the spoon of the
porte au caustigue.  Much caution is therefore necessary, lest we in-
flict a severe injury upon the ends of the ductus ejaculatorii.  In or-
der to avoid such an occurrence, I  have  been obliged  in  these cases
to use a No- 9. catheter, with a small pbitina syringe so adapted to
it, as to make  a porte  au caustigue, for the application of the solution
of the nitrate of  silver, to the  irritable part of the urethra;  and  have
found it entirely  safe and very successful.
   If strictures be the  cause of the  irritation, remove them.  When
all the above means fail  in producing a cure, I have advised  the pa-
tients to try the life of a sailor, for a time; and  when the advice has
been followed, I have known  them to be perfectly  cured.   Sailors
are a class  of men, who rarely suffer from this disease.—Ed.]

                            chordee

Takes place when the  inflammation is  not confined merely to the
surface  of  the urethra and its  glands,  but  affects the corpus spongi-
osum: in this circumstance,  an extravasation of fibrine occurs in
that texture, which becomes incapable of yielding  in  the same de-
gree as the corpora cavernosa.  Hence,  during erections, there is
a curvature of the penis—it is bent, as it were, with  the concavity
mostly at the lower side of that organ.    The patient may suffer se-
verely from erections, conjoined with the state of the penis  termed
chordee;  for the irritation of gonorrhoea  keeps up  a determination
of  blood to the part,  and it is difficult altogether to prevent them.
   When much  inflammation is present, we may bleed  the  patient
from  the arm, and, in all cases, apply leeches, cold lotions, or use
cold bread-and-water poultices, with which maybe blended  the ex-
tract of belladonna.
   The bowels are to be kept open, and the tincture of hyosciamus,
or what is still more efficient,  the vinum  colchici,  the acetate of
morphia, or some other preparation of opium,  administered,  with
the view of lessening the disposition to erections.
   After the inflammation has subsided, the remaining hardness may
be dispersed by frictions with ointment of hydriodate of potassium,.
or camphorated mercurial  ointment.

                      SYMPATHETIC  BUBO,

One  of the  occasional consequences  of  gonorrhoea,  arises   from
mere irritation,  and not from the absorption of any virulent  matter.
It  is a simple inflammation  of one or more of the inguinal  glands,
much less frequently advancing to suppuration  than a venereal bu-
bo. 
 286  DISEASES  OF THE GENITAL AND URINARY ORGANS.

    Treatment.—Antiphlogistic, with cold evaporating lotions, or fo-
 mentations and poultices, leeches, aperient medicines, and quietude.

 INFLAMMATION  EXTENDING  TO  THE  MUCOUS  MEMBRANE  OF
                         THE BLADDER

 Is  another occasional effect of severe claps; it is attended with ex-
 treme suffering and annoyance.  In this  state, the bladder is so ir-
 ritable, that it cannot contain the smallest quantity of urine, without
 the patient being put to intolerable pain;  and when this affection is
 joined, as it frequently is, with a difficulty of discharging that fluid,
 and even with retention, the patient's agony may well be conceived.
 This state of the bladder demands prompt and vigorous measures:
 venesection, brisk purgatives, leeches to the hypogastric region and
 perinaeum, the warm slipper-bath, fomentations, and draughts of the
 camphor mixture, with ten minims  of the tinct. of opium and fifteen
 of that of henbane, every three or four hours; or an injection of the
 mucilage of starch with forty drops of opium into the rectum.   The
 uva ursi is another medicine frequently  prescribed in these cases, in
 the quantity of ^j. or 5SS.  every six hours.

                           PHIMOSIS

 Is either a congenital  smallness of the opening of the prepuce; or
 else an accidental narrowness of the same ortfice preventing the glans
 from being uncovered, and arising from any circumstance that  pro-
 duces  a  swelling of the prepuce whether inflammation, or an infiltra-
 tion of the cellular tissue of the part with urine, or a serous fluid.   It
 may arise from simple excoriations caused by the confinement and
 acrid  quality of the sebaceous matter  secreted round  the  corona
 glandis;  primary  venereal sores,  particularly  those which are form-
 ed  on  the inner  surface of the prepuce,  or  which  take place  in
 clusters near its orifice.   Phimosis is also sometimes induced  by
 sores on  the glans, especially such as  are on or near  the corona
 glandis, or on one side of the fraenum.   Occasionally, the pressure
 of warts against the prepuce will  bring on  phimosis.    Sometimes
 the inflammation of the prepuce partakes of the erysipelatous char-
 acter,  and, whether it be of this kind or of the phlegmonous,  the
 part frequently has an oedematous or anasarcous appearance  behind
 the glans.  When chancres occur, phimosis sometimes  leads  to
 serious evils; for  the glans, being  then situated between the sores
 and the orifice of the prepuce,  the pus may be prevented  from es-
 caping.   The result  is an accumulation of matter round the  cor-
 ona glandis: ulceration  begins  within the prepuce; makes  its  way
 through it; and the glans  protruding through  the new opening, the
whole  prepuce seems thrown in the opposite  direction.  In certain
instances, the swelling and  thickening  of the prepuce cause such 
PHIMOSIS.
287
compression of ulcers on the glans, that unless a timely division of
the prepuce  be made,  the whole of  the glans is  destroyed by
sloughing.
   Sometimes, phimosis produces obstruction  of the passage of the
urine through the orifice of the prepuce, and this fluid may then in-
sinuate itself  into the cellular  tissue of the part;  while in other ex-
amples, the retention may lead to ulceration of the urethra, and ex-
travasation of urine around it.
   Phimosis is not then itself  essentially a venereal  complaint: for
it may arise from any kind of irritation  producing inflammation of
the prepuce,  whether a gonorrhoea, a chancre, simple excoriations,
the pressure and irritation of  warts,  or an accidental  injury of the
part.   When it arises from  a  true venereal sore, it is itself only an
example of the common  inflammation usually  produced  in the vi-
cinity of the specific disease.
   The phymosis, from simple excoriation, and from the irritation
of acrid secretions  lodged  under the prepuce, requires that tepid
water,  or the diluted liquor plumbi acetatis, should be frequently in-
jected  between the prepuce  and  the glans, so as to keep the parts
clean.   The penis may also be covered  with  linen  wet with  the
lotion, the  patient be kept in  bed,  or,  at all events,  from walking
about, and purgative medicines  and a low diet prescribed.  When
the inflammation is more severe, leeches or sacrifications  will be
useful, and the  bleeding  should be promoted  by bathing the penis
in warm  water.
   The phimosis, originating from severe  gonorrhoeas, chancres, or
other sores, may require, in addition to local and even general bleed-
ing, warm emollient  poultices, or the  steam  of hot  water.   The
sores are to be kept clean by  freely throwing between the glans and
the prepuce a weak solution of the sulphate of zinc, the black wash,
or a lotion composed of two  grains of  the bichloride  of mercury,
gj. of the extract of  opium, and six ounces  of distilled water; or,
when the inflammation is considerable, we may simply inject under
the prepuce a tepid solution of gum arabic, with which the extract
of opium is blended, in the proportion often grains to six ounces.
   When a chancre is complicated with violent inflammation of the
prepuce  and phimosis, I believe, that the best  practice is to sus-
pend  the use of mercury, and direct  our endeavors  to the reduc-
tion of  the swelling and  inflammation of the part.   When these ef-
fects subside, mercury may be more advantageously  continued.
   The following are the circumstances, which, in cases of phimosis,
sometimes render the division of the prepuce necessary:—
   1st. An accumulation of  matter  under  the prepuce secreted
by sores in that situation, and not admitting of being readily wash-
ed out by  means of a syringe.  Here, if we neglect to divide the
prepuce, an ulcerative process  vakes place upon its  inner  suface,
and forms an opening through  which the glans will protrude with a 
288   DISEASES OF THE GENITAL AND URINARY ORGANS.

very great degree of deformity.   But  this is not the only  evil; for
the chancres,  under  these circumstances, always  continue  to  en-
large, and sometimes the glans and prepuce both become involved
in gangrenous mischief.
   If the glans had  already protruded  through an ulcerated opening
in the side of the prepuce, the best plan would be to  put  a direc-
tor from the natural  opening through  the new one, and  divide
the intervening  portion of skin.    In order to  stop  the  progress
of ulceration  from  within,  and  to prevent the protrusion of the
glans,  Mr.  Hunter did  not  divide  the prepuce  completely,  but
merely  punctured  it, so  as to let out the matter, as he would have
done in  any other common abscess.
   In cases of permanent  phimosis, combined with chancre,  M. Ri-
cord concurs with such  practitioners as recommend  the  operation
to be deferred, unless there is  an urgency for it, until the chancres
are healed, and thus all risk of the wound becoming inoculated will
be avoided.   If  circumcision, which he  prefers, be  performed,
while a chancre is present, he advises the sore to be  taken  away if
possible, together with the portion of the prepuce;  a method, which
I have sometimes followed.   But, if the chancre be left, M. Ricord
immediately rubs it with caustic.
   2d.  Sometimes  we meet with cases in which the compression of
the swollen prepuce acts injuriously  upon sores of the glans;  and
when there is  reason  to suppose that this  cause is likely seriously
 to retard their cure, and  even bring  on sloughing, we are justified
in dividing the prepuce.
   3d.  Phimosis,  arising from  the puckered  and  contracted state
 of the orifice of the prepuce after chancres are healed.
   4th.   Phimosis from the pressure and irritation of large  warty ex-
 crescences.
   5th.   Examples  of congenital  phimosis producing impediments
 to the discharge of urine in infants, or even leading to the formation
 of calculous substances  under the foreskin; and, in adults,  creating
 an obstacle  to  sexual intercourse, and, in  old persons,  causing a
 predisposition to cancer of the organ.
    There are several methods of operating.  One consists  in pass-
 ing a director under the middle of the upper part of  the prepuce as
 far as the corona glandis, and then, with a pointed curved bistoury,
 slitting the prepuce  up to the point  to which  the director extends.
 We push the bistoury with its back  in the groove of the  director
 gently along this instrument, until  the  point reaches nearly to the
 corona glandis, when by raising the point  and  bringing the  edge to-
 wards  us, the division is made in an instant.
    2d.   Instead of this mode of dividing the prepuce, Cloquet  and
  Wallace prefer making an incision, parallel  to the fraenum, at the
  under  part of the  prepuce; because the line  of the incision thus
  formed, is found to be, as soon as the prepuce is drawn backwards, 
PARAPHIMOSIS.
289
transverse in place of oblique,  or parallel  to the axis of the penis,
and those angular flaps  of skin  are avoided,  which  cause great
deformity when the operation is performed at the upper part of the
prepuce.  This plan  I sometimes adopt.  M.  Ricord objects to
it, as leaving a deformity very similar to  that of hypospadias.
  3d. A third method consists in the performance of circumcision:
the prepuce  is drawn forward, and taken  hold of with a pair of for-
ceps; as much  of the extremity  of it being left out of their grasp
as needs removal:  with  one stroke  of a common  scalpel,  guided
along the forceps, as a pencil is along a  ruler,  a complete circle of
the prepuce  is cut away.   In applying  the forceps, as  the upper
part of the  prepuce is quite unconnected  to the glans, and longer
than the lower portion, which is also united to the fraenum, of course,
a more  considerable piece of the prepuce above should be left in
front of the  blades of the instrument than below.
   After circumcision  has  been performed, the  inner membrane of
the prepuce  and the outer skin are seen with their edges more or less\
separated  from one another.  If the  inner membrane should  still
seem tight, it is to be slit up, or cut with  scissors.   Then, in order
to keep the edges of the outer and inner skin of the prepuce togeth-
er, a small  suture may be passed  through  them.   If the artery of
the fraenum bleed copiously, it must be tied, or twisted.   For the
prevention of inflammation and erection, cold water is to be applied,
and camphor and opium,  or the acetic extract, or the tincture, of
colchicum prescribed.

                         PARAPHIMOSIS

Is the ca*se,  in which  the  prepuce is drawn behind  the glans penis,
and cannot  be brought  forward again.   If the  opening in the pre-
puce be narrow, as  is often the case when the part is in an inflamed
state, it will, when drawn behind the glans, produce such a constric-
tion of the penis, as is not only  followed by considerable swelling
of the glans, but by the greatest difficulty,  or even impossibility, of
getting the glans back  again through the narrow  part of the prepuce,
The glans is uncovered and of a livid color, its corona being ovei>
lapped  by a  tumid ring, formed by the oedematous lining of the pre-
puce.  Behind this tumid circle is the seat of stricture or compression,
produced by the contracted  orifice of the prepuce.   The extent of
the swelling  backwards is various in different instances.   Neglected
cases sometimes terminate in sloughing either of  the glans, or  the
prepuce, or  both  parts together.
  From what has been said,  we may readily understand  why a
phimosis should frequently change into a paraphimosis,  when  the
prepuce is imprudently drawn too far back.
  In the treatment, if the case be recent, the inflammation  consid-
erable,  and  the  patient a strong  subject, venesection should be
  vol.  n.                   25 
290         DISEASES OF THE ANUS AND RECTUM.
practised.   The indication is to reduce the glans to as small a size
as we can, by the application of cold lotions, or snow, or ice-water,
and then compressing it equally, and unremittingly, for a  few min-
utes, between  the  ends of the fingers  and thumbs of  both  hands;
and when we have  pressed as much blood out of it as is practicable,
and reduced it to the smallest  size, we are  then to press it  back
with the  thumbs through the constriction of the  prepuce,  while the
fingers are used at  the same time for bringing the prepuce forwards
over the  glans.
   When the attempt does not succeed, we may  have  recourse to
leeches,  purgatives, punctures in the anasarcous part of the swell-
ing,  and  cold applications; but if we cannot succeed, notwithstand-
ing these means and  the manual proceedings which I have describ-
ed, and the  constriction be such as to threaten to produce slough-
ing, the portion of the prepuce forming the constriction must be di-
vided with a sharp-pointed narrow bistoury.   The operator  will al-
ways find the stricture behind  the corona  glandis,  and  separated
from it by a tumid  ring, consisting of the  cedematous lining of the
prepuce.  It is therefore in a kind of nepression, or groove.  Into
this, the  point of the  knife is  to be passed,  deeply enough to go
under the stricture, which may then be divided by cutting upwards.
No preliminary  incision is necessary.
   Even when the stricture has been cut, the adhesive inflammation
may prevent us from immediately  bringing the  prepuce  forwards;
but as the constriction has  been  removed, no  sooner does the in-
flammation abate, than the parts resume their natural state.
•
     DISEASES OF  THE ANUS  AND RECTUM.

                ABSCESSES.--FISTULA  IN AN0.

  This  last term is applied to almost every abscess which  breaks
in the vicinity of the anus; but very improperly; for,  the  idea  of
there being a fistula naturally leads to the adoption of measures to-
tally different from those  usually required for the cure of abscesses
in general.   Sometimes, the complaint makes its attack in ihe form
of phlegmonous inflammation, attended with a  frequent, full  pulse,
and heat and dryness of the skin.   The formation of matter is often
preceded by a fit of shivering.  A  part of the buttock  near the
anus is  considerably swelled,  and presents a  large  circumscribed
hardness, the middle of which soon  becomes very red, and  matter
forms in its  centre.  On  other occasions,  suppuration is preceded
by erysipelatous  inflammation, without  any of the  circumscribed 
FISTULA IN  AN0.
291
hardness which characterises the foregoing  tumor.  The  redness
spreads more extensively;  the disease is more superficial; the quan-
tity of matter small; and the cellular tissue sloughy  to a considera-
ble extent.   Sometimes the complaint begins somewhat  like a car-
buncle.  The skin is of a  dusky red,  or purple color, and although
harder than in the natural state, not  nearly so tense as in phlegmo-
nous  or erysipelatous  inflammation.  At  first, the pulse is full  an
hard; but,  if no relief be obtained,  it soon  becomes unequal,  low,
and  faltering;  and the strength  and  spirits are  greatly dejected.
The matter, formed under the skin,  is small  in quantity,  and bad in
quality, and the cellular tissue is  deeply gangrenous.   This species
of the disease affects persons, whose  habit is either naturally  bad,
or has been rendered so by intemperance.
   These different affections often influence  parts in the neighbor-
hood of the disease.   Hence retention of urine, strangury, prolap-
sus ani, tenesmus, piles, diarrhoea, or obstinate costiveness.
   Sometimes the  abscess  begins as an  induration of the skin  near
the  anus;  but  without  pain,  and alteration  of color; the hardness
gradually softening and suppurating.
   The matter may either point in the  nates,  at a  distance from the
anus; or near the latter part; or in the perinaeum.  The matter  may
escape from one opening, or from several.   Sometimes there is not
only an external aperture,  but another internal one,  communicating
with the cavity of the intestine.   In other instances, there is  only
one external or internal opening.
   The matter may be formed at a  considerable  distance from the
rectum, which is not even  laid bare by it; in other cases, it is laid
bare, but  not perforated ;  sometimes it  is   both  denuded  and
pierced.
   Many abscesses about the anus are connected with a bad state of
the health.   When quite local diseases, they  generally  arise from
obstinate costiveness, and  the irritation of the  mucous  membrane
and cellular tissue of the rectum  by  the passage of indurated faeces.
Individuals, who have long suffered  from piles, are particularly lia-
ble to abscesses near the extremity  of the rectum.   Severe  diar-
rhoea, accompanied with tenesmus and great  determination of blood
to the rectum, has also been known to bring on the complaint.   Sir
Astley Cooper is of opinion, that the most common cause is disease
of the liver, which, preventing the free return of blood from the in-
testines, and influencing their secretions, leads  to inflammation  near
the rectum.*  In a few instances, abscesses  at the side  of the  rec-
tum appeared  to have  arisen from  the  penetration of the mucous
membrane, and sphincter muscles, by fishbones,  or other irritating
extraneous  substance in the bowel, one or two  interesting examples
of which are recorded by Sir  Benjamin Brodie.
• Lectures, vol. ii. pp. 827, 328. 
292         DISEASES OF THE ANUS AND  RECTUM.
   When the inflammation is phlegmonous, Pott advocates the doc-
 trine, that the thinner the skin  is suffered to  become,  before the
 abscess is opened, the better; but the generality of modern surgeons
 make it  a rule to  open every abscess near the rectum  as soon as
 a fluctuation can be felt.   This affords the best chance of prevent-
 ing a fistula and sinuses  extending far up.  If the patient be of a
 full, sanguine habit, venesection, leeches,  and mild purgatives, are
 proper in the early stage.  The confectio sennae with sulphur is
 one of the most eligible aperient medicines.   An  emollient poultice
 is the best application;  and if the pain be severe, leeches and fo-
 mentations should  be employed.
   When the  attack is  of an erysipelatous  kind, and  there is a
 sloughy state of the cellular tissue, the sooner the part is opened
 the better.   If we wait for the  matter  to  point, we shall  wait for
 what will not happen, at least not till  after a considerable  length of
 time, during which the disease  will  extend itself, and the  cavity of
 the abscess be greatly increased.
   When the fistula in ano  commences with that kind of inflamma-
 tion which a carbuncle exhibits,  calomel, with  opium,  and  mild
 aperient medicines, may  be prescribed in the early stage; but the
 patient will not bear much depletion;  and very  soon tonics,  with
 ammonia, or wine, will be required.  The  part should be opened
 early by a very free incision.
   All suppurations in the vicinity  of the anus  do not necessarily in-
 terest the rectum;  sometimes the matter is so  distant from the in-
 testine, that the surgeon has no  more to  do with this part  than if it
 did not exist, and the abscess is to be treated upon  general princi-
 ples.  Under simple treatment, the necessity of meddling with the
 rectum  will often be  removed.  But it  more frequently  happens,
 that the  intestine,  although not pierced by the  matter, has yet been
 so denuded, that the fistula will  not heal, without laying ihe cavity
 of the abscess and that of the intestine into one.   The difficulty of
 healing  many abscesses near the rectum  depends  upon their  being
 influenced by the action of the  sphincter and  levator ani  muscles,
 which have  a constant tendency to  prevent the union of the  granu-
 lations and coalescence of the sinus.
   The  operation consists in dividing the rectum,  from the top  of
 the hollow,  in which the matter is lodged, down to the anus.  Thus
 the  fistula is  converted  into  an  open  wound.  The course and
 extent of the fistula is to be first ascertained.  The patient may kneel
 on his bed,  and a* the same time lean forwards on his elbows, while
Jhe Iu?ees are kept close together; or he may get  up, lean  forwards
on the hack  9*" * chair, and p^ce his knees  together.  The  fore-
finger pf the most ppnvenient hand,  according to the side on which
the fistula is situated^ liaylpg been oiled and passed into the rectum,
 the surgeon introduces a narrow purred probe-pointed bistoury into
 the fi§tuja, will) its edge turned  toward^ the rectum, until it has tra- 
FISTULA IN  AN0.
293
versed the fistula, and the probe-point is felt pressing against  the
extremity of the finger within the bowel.   Then, by making a little
pressure with the knife, held in a particular manner, the rectum  will
be  pierced,  and  the probe-point  having  come in contact with the
end of the finger, the latter is steadily withdrawn;  and as the knife
rests upon and is made to follow  it, the edge divides all the parts
intervening between it and the anus, including the external sphincter.
When a silver director is bent, it will sometimes pass through the
whole track  of the fistula into the  rectum: then the division of all
the parts, interposed between it and  the anus,  should be performed
under  the guidance of this  instrument.   Or the  director may be
employed  when the  course  of the fistula is  tortuous.   Then the
director,  if used, is to be  withdrawn, and the  operation  is to be
completed, by bringing the  knife out, with its point applied to the
finger,  within the intestine.   In this manner, all  that is between the
edge of the  knife and the anus must obviously be divided.   The
sphincter muscle being included  in the cut, not  only is there a  free
and ready escape  of the matter, but the action of the  muscle
which creates such a disturbance of the part,  and prevents its heal
ing, is for a  time suspended.
   Immediately after the operation, a soft  dossil of fine  lint should
be introduced, from the rectum, between  the lips of the incision.
 This first dressing should  remain  till  loosened  by suppuration.
 Afterwards, lint dipped  in sweet oil or tepid  water, is  one of the
 best applications.   A T bandage  is usually employed.
   We  have now to  consider fistulae in ano, in the  state,  in which
 they are after having spontaneously burst.
   When the matter has made its escape  only through  an external
 opening, the case  is termed a blind external fistula.   Sir Astley
 Cooper has  several times known a fistula  form on  each  side of the
 anus, and communicate round the rectum.   He examined the body
 of a man, who died of a discharge from  a fistulous opening in the
 groin, and who had a fistula in ano:  the fistula  passed under  Pou-
 part's ligament, took the course of the vas deferens, and descended
 into the fistula in  ano.   Sometimes the fistula only just reaches the
 spincter, and is extremely small, appearing at first merely as a  sup-
 puration of  one of the follicles of the anus.   Sometimes it reach-
 es four  inches up the  side of the  rectum.*   When  there is an
 opening in the intestine, and none  in the skin, the fistula is called  a
 blind internal fistula.  Fistulae, having an opening both  in the skin
 and gut,  are termed complete.   The first and  last cases are the
 most common.  A probe is to be introduced  to ascertain  their na-
 ture, and  the operation, already described, is the proper one for ob-
 taining a cure.  When there are several openings, and correspond-
• Sir Astley Cooper's Lectures, vol. ii. pp. 326, 327.
                 25* 
294         DISEASES OF THE ANUS AND  RECTUM.
ing sinuses, they are all to be divided with a curved bistoury, so as
to make one cavity of the whole.
   In cases of blind internal fistule, if the bursting and discharge
of the matter should not produce a cure,  which they sometimes do,
though very seldom, an external opening  is  to  be made, and  then
the same operation, as has been already described  for other cases,
is to be put in execution.  The place for the opening is always suf-
ficiently denoted by the induration.
   Sometimes the health will require to be improved before a cure
can  be accomplished, and many patients, who cannot  recover  in
hospitals, do so on removing into a better air.   The medical treat-
ment of fistula in ano, connected with disease, consists in restoring
the secretions of the liver, and intestinal tube, by giving the chlo-
ride of  mercury, or the pil. hydrargyri at night, and  the compound
infusion of gentian, with soda and rhubard, twice  in the  day.*
  If  any organic or  visceral disease exist;  such as disease of the
liver or lungs, or carcinoma or stricture of the rectum,  the opera-
tion ought not to be performed; for, under these circumstances, the
fistula, though laid open, will not heal, or, if it should,  the  visceral
disease  will advance with a quicker pace.f
  Besides  the foregoing kinds of  abscess  near  the  anus, piles
sometimes  suppurate, and  matter forms  in  their centre, as will be
presently explained.  Occasionally, also, abscesses  form in front
of the vertebrae, descend  into the  pelvis behind  the peritonaeum,
and bursting somewhere near the termination of the rectum,  become
fistulous.   The operation in such a case would  be entirely  useless.

                   PILES, OR HEMORRHOIDS.

  In  their texture,  piles  are subject to a  great  deal  of  variety.
Sometimes  they are merely dilated  veins, or varices, situated near
the anus, or lower portion of the rectum,  forming  prominences cov-
ered by its  mucous membrane,  or  the delicate skin near the ;anus,
and from which a  bleeding takes place,  whenever there is a great
determination of blood to the parts.
  In  other still more frequent cases, the texture of hemorrhoidal tu-
mors  is more complicated; many of them being characterised by an
areolar, soft, spongy structure, filled with blood.   At periods, when
these are in a quiet state, free from irritation,  and  without any  par-
ticular determination of blood  to  them,  they  are small and shriv-
elled; but in the contrary circumstances, they swell, become firmer,
undergo, as it were, a kind of erection, and  blood is voided from
their surface.   Hence, their texture is compared by French pathol-
ogists to the erectile tissues.  Numerous arterial branches are distrib-
* Vol. cit. p. 328.
t Sir B. C. Brodie, Lond. Med. Gaz. Oct. 1836. p. 29. 
PILES-
295
uted to them.   Chaussier found, that if an incision bemadefn them,
and a colored fluid thrown into the; hemorrhoidal arteries, it  will is-
sue from numberless small apertures within the sweHings-
   Other hemorrhoidal  tumors ccneist of one  or  more  cysts, or
cells, smooth  internally, more or less vascular,  retaining tne blood
for variable periods, but every bow and  then bursting, and occa-
sioning hemorrhage.
   Lastly, some hemorrhoids, originally  having cavities, or cells,
are gradually  converted into solid swellingsby the effects of repeat-
ed attacks of inflammation, and the effusion and organization of fi-
brine.
   Hemorrhoids are divided into internal and  external, according to
their situation, either above the sphincter muscle, and in the inferior
part of the rectum, or below the sphincter, near the verge of the anus,
under the delicate thin  integuments by  which  this part  is covered.
 Bqt, as an  internal pile  may protrude below the external  sphinc-
ter, the best criterion is its texture; for it is always covered  by the
mucous membrane of the bowel;  while an external pile is  invested
by the  delicate skin near the anus.  Those  internal ones,  which
 resemble varices, lie under the mucous membrane, which  is often
 adherent to their surface, and so  thin, that their bluish color can be
 plainly distinguished through  it.   Varicous  piles  make their ap-
 pearance,  chiefly when the parts  are in a state of congestion, in the
 form of dark blue, elastic  knobby swellings, not attended  with
 much pain, yielding to  pressure, but returning immediately it is dis-
 continued.   These venous dilatations under the skin, or under the
 mucous membrane of the rectum, are generally only a small  part of
 those which exist around the bowel.  M. Begin has  sometimes
 found the lower portion of the rectum  involved in a plexus  of en-
 larged veins,  composing a thick  vascular zone around it,  and so
 gorged with blood, that if it  had  been cut in the  living subject, a
 very dangerous hemorrhage must have been the consequence.
   Internal hemorrhoids of the spongy and cellular kinds are always
 situated between the fleshy fibres and the mucous coat of the bow-
 el, under which they  project.   They  are  of different  sizes, from
 that of a pea to that of a nut, walnut, or even a small egg.   Their
 number is equally various;  sometimes only  one  or two; but occa-
 sionally so  many, that the affected part of the  bowel  is filled  and
 distended  with them.   Sometimes only a small  portion  of them
 projects into  the bowel, the greater part of their mass being  lodged
 in its cellular tissue;  but,  in other instances,  the whole or  greater
 portion of the swelling directs itself towards the interior  of the bow-
 el, and being gradually detached  by the repeated passage of  the fe-
 ces from its original connection, at length hangs by a kind of pedi-
 cle into the cavity of the rectum.
   External  hemorrhoids of this  kind also sometimes  form slight
 prominences  under the thin delicate skin near  the anus;  but  in  oth- 
296         DISEASES OF  THE ANUS AND RECTUM.
er examples,  considerable  and  permanent  tumors,  which  were
often termed marisce by the old surgeons, from their shape and ap-
pearance.
  Various circumstances may tend to  bring  on a determination of
blood to the  rectum,  followed  by hemorrhage  from  the mucous
membrane, and,  in  many instances,  by the  tumors  called piles.
Plethoric individuals,  and others  in whom  the  circulation in the
branches of the vena portae  is obstructed, are  particularly liable to
them.   They are seldom met with in very  young persons, being
scarcely ever  produced  till the  body  is completely developed in
breadth as well as height.  An age between thirty and  forty is the
most common period for them to begin;  and  if in a full habit, they
mostly continue during life.   In  the male  subject,  the occasional
bleeding, from piles  is frequently regarded, and not without reason,
as a salutary evacuation.
   In the other sex, menstruation seems  to render this other spon-
taneous kind of depletion unnecessary; but, on the natural  discon-
tinuance of the menses, piles are disposed to form, and, in full ple-
thoric women, the bleeding  from  them may then  become a substi-
tute for the uterine evacuation.   Also during  pregnancy  and  after
delivery, many women are troubled with piles,   in these cases the
enlargement of the hemorrhoidal vessels depends upon the suspen-
sion of  the menstrual  discharge,  the compression of the  veins by
the gravid uterus, and the efforts and local irritation accompanying
parturition.
   Whatever tends to bring on plethora creates a disposition to he-
morrhoids; as taking  more food  than nature can properly dispose
of, eating high-seasoned dishes, and drinking too much  wine and oth-
er fermented  liquors.  Such excesses, combined  with an indolent
or sedentary life, will be still more likely to induce the disease.  A
similar effect may also proceed from any other circumstances  occa-
sioning  a great determination  of blood to the rectum;  as the  abuse
of aloetic purgatives, and stimulating glysters; habitual constipation;
the (irritation  of the  bowel  by   the  passage  of indurated feces;
and excesses  in venery, whereby a larger quantity of blood is made
to pass into the vessels of the lower part of the  rectum,  as well as
into those of  the genital organs.
   By the expression hemorrhoids, some of the old writers signified
bleedings from the rectum, whether attended with piles or not.  In
fact,  a congestion of the hemorrhoidal  vessels is sometimes terminat-
ed b\  a copious discharge of blood  from the  mucous membrane;
but repeated congestions will not always end in this way, but often
in inflammation, and the change in the size of  the veins,  or the for-
mation  of the tumors already  described.
   Few diseases are more painful than piles  in the state  of inflam-
mation.  About  the fundament, there is an excessively painful feel-
ing of tension, burn ng heat, and  weight, extending from the anus, 
PILES.
297
through  the  pelvis, and  to the neck of the  bladder in  the male,
and to the womb in the  female.   The pulse is- hard, quick, and
contracted.   The patient  is continually wanting to go to stool,, and
the efforts made for this purpose generally have no other effect than
that of subjecting him to severe torture.   Sometimes the evacuation
of the urine is attended with difficulty.   The anus and surrounding
parts  are  red,  gorged  with blood,  and the seat of prominent,
tense, elastic swellings^ which are of a purple or deep brown color,
and  extremely painful on being touched.   The sufferings are still
greater, when the inflamed  mucous coat of the rectum is propelled
down, so as to form a circular projection,, which is  strangulated by
the sphincter muscle.   A corresponding increase of suffering  re-
sults  from a similar  constriction  of inflamed hemorrhoids by the
fibres  of the  same organ, the action  of which  not only prevents
the  reduction  of  the protruded  swellings   into the  bowel,   but
interferes with the return of the blood from them, and thus their ten-
sion and  size become still further increased.   Under these circum-
stances, it may be impossible for the patient to empty the bowel, and
he may be attacked with the same symptoms as are noticed in eases
of strangulated hernia.
   When the irritation of the rectum, resulting from  piles, is less in-
tense, but protracted, a frequent consequence is a morbid secretion
of mucus from its interior.  In  other ii istances, the effects  are a
thickening of its coats, a contracted  state: of the anus, and great in-
duration  of the adjoining cellular tissue.   Piles, which have been
repeatedly inflamed,-sometimes occasion a permanent spasmodic ac-
tion of the sphincter, or numerous deep  fissures at the margin of the
anus,  rendering  the  evacuation of the  feces exceedingly painful.
Lastly, abscesses and fistulae may beconae complications of hemor-
rhoidal  swellings.   Inflamed  piles occ asronally suppurate in their
centre; and the matter,  which forms within them, may long contin-
ue to be  imperfectly discharged from the na through a fistulous open-
ing on their surface.
  When  persons experience little inconvenience from the tumors, or
the hemorrhoidal flux, as it is termed, tal ces place from time to time in
a plethoric subject, there is in the first case no real occasion for the
removal of such piles; and in the seco nd, the stoppage of the peri-
odical bleeding may create  a risk of 1 >ringing on some other more
serious disease like apoplexy, which the;  discharges of blood from the
rectum tend to keep off.   It  is  on this  account, that piles are some-
times regarded as  safety-vales  for  th j  contitution.   The  preven-
tion of constipation by the mildest lax: itives is here the chief indica-
tion.  The lenitive electuary, with sul phur or small doses of castor
oil, are commonly preferred.  Even   when the evacuation of blood
from the  anus is rather profuse, it is n ot always proper to check it.
So  long  as the pulse is  strong, the (:olor of  the face natural,  the
muscular system  vigorous, and  the pa tient feels relief from the de- 
298         DISEASES OF THE ANUS AND  RECTUM.
 pletion, it is best not to interruptit.   But, if the countenance be pale,
 the debility considerable, and the pulse much  reduced, the patient
 should  be kept in the recumbent posture,  cold  acidulous injections
 be thrown up the rectum, cold  lotions applied  to  the anus, and all
 his beverages be  of a  low temperature, and acidulated with nitric
 or sulphuric acid.  If  there  were pain about  the rectum, and the
 pulse not too  much reduced, venesection might also be  proper,  as
 calculated at  once to  relieve  the irritation of  the  part,  and to stop
 the determination of blood to  it.
   When  the hemorrhage  recurs  very frequently from an internal
 pile, or the tumor often descends, and inflames from constriction
 by the  external sphincter, the tumor should be extirpated.   By the
 patient sitting over a pan of warm water, and making efforts as if at
 stool, the tumor  may almost always be made to present itself at the
 anus, and then can be  easily  taken hold of with  a tenaculum for-
 ceps, and  tied.    On  account of the profuse hemorrhage, liable to
 follow the excision of internal piles, the removal of them by ligature
 is now  almost constantly  preferred  by the London surgeons.   If
 the pile cannot be made to  descend in  this way, a pint or two of
 warm wrater may be thrown up the  rectum,  and on its discharge
 taking place, the tumor will often present itself.
   When an internal pile is above a certain size, it should be trans-
 fixed with a needle and strong double ligature,  one half of which is
 to be firmly tied  over each side of the neck of the tumor.   The
 surgeon, after having secured  each  pile in this way, may cut off its
 convex portion,  and snip off both ends of each ligature close to the
 knot, returning the remains  of the pile and rest  of the  ligatures into
 the rectum.  On the  day before the  operation, the bowels should
 be emptied  by means of a dose  of rhubarb, so that there may be no
 necessity  for  another  evacuation for  two  or   three  days.   After
 the  ligatures  have been detached, which usually happens in a
 week, and a little time has been afforded for the healing of the sores
 left after their  separation,   the  patient should   take some  lenitive
 electuary and sulphur every night, and use a lavement of cold water
 every morning.   Thus he will prevent a recurrence of the disease.*
 External piles may be  safely removed  with a cutting instrument.

        INFLAMMATION  AND  STRANGULATION  OF PILES.

  Another inconvenience from  piles,  and, in some cases, not less
 serious  than that  resulting  from their magnitude,  or  the bleeding
from them, is their inflammation, which,  in its very  beginning, is
usually  conjoined with a protrusion,  either of the  hemorrhoidal
swellings,  or of a circular prominence of  the rectum, in a state of
* Sir B. Brodie, Lond. Med. fjaz. 1834—55, p. 844. 
       INFLAMMATION AND STRANGULATION  OF PILES.     299

great turgescence.  Nothing can exceed the sensibility which these
parts acquire from distension, and the pressure made on their base by
the sphincter muscle.  Violent  nervous symptoms,  extreme rest-
lessness, severe febrile disturbance, and even  subsultus tendinum,
may arise from the inflamed and strangulated state of hemorrhoidal
swellings.
   Here the first indication is to  push up the tumors completely be-
yond the grasp of the sphincter muscle.  The patient is directed to
rest on his knees and elbows, and the swellings, having been smear-
ed with a little spermaceti ointment, are to  be gradually  pushed up
by one of the surgeon's fingers, with the intervention of a fine nap-
kin.  Then, in order  to prevent the protrusion  from taking  place
again, a thick compress is to be applied to  the anus, supported by
the T bandage.  At the same time, the patient is to be kept strictly
quiet in bed, lying on his  back,  and restricted  to a very low diet.
Cold water is now and then to be thrown up the rectum, and, in the
greater number of cases, local  and general bleeding is indicated.
When inflamed and strangulated piles cannot be returned  into the
rectum, antiphlogistic treatment  is to be employed, especially vene-
section,  leeches,  and either cold  or warm emollient applications.
Frequently I have at o:ice relieved  the patient by cutting off inflam-
ed piles, which did not admit of immediate reduction.  In other ex-
amples, where the unus is surrounded  by a circular  prominence of
protruded,  turgid, inflamed  mucous membrane, attended with ex-
cessive pain, a few  deep  incisions made in it will  frequently give
prompt relief, and bring about such a diminution of the part, that it
may be  returned.
   What happens when the foregoing methods fail to accomplish the
reduction of constricted hemorrhoids?   If the  inflammation has not
risen above a certain  pilch, the irritation generally begins to abate in
the course of four or five  days,  or a  week,  accompanied  by  a dis-
charge  of blood, mucus, or pus from the  surface of the tumors,
which,  becoming  diminished,  gradually return  into the rectum.
 These desirable changes are to be promoted with emollient applica-
tions, leeches, and other means already^ specified.
   In a worse description of cases, hemorrhoids, whether in the shape
of tumors, or a prominent thick ring of the mucous coat, are  so for-
cibly strangulated that they mortify.  I have seen several instances,
in which  this has terminated in a cure.  Gangrene of strangulated
piles, however, may extend  beyond  the tumors, thus involving the
lower part  of the rectum  in the mischief, and  bringing on likewise
 phlegmonous erysipelas and gangrene of the cellular tissue, not only
around  that bowel, but in the parts  external to the anus.
   External piles, inflamed, but  not strangulated, may often be ren-
dered less painful by anointing them  with a cerate containing pow-
der of galls and a little of the extract of opium,  or belladonna; then
applying a cold lotion to them, and, if requisite, leeches;  care being 
300
DISEASES  OF THE ANUS AND  RECTUM
 taken to keep the patient in the recumbent posture, and on a strict
 antiphlogistic regimen.

  MUCOUS AND PURULENT DISCHARGES FROM  THE  RECTUM,

 Arising from  piles, require different modes of treatment according
 to circumstances.   Thus, when piles suppurate in their centre, and
 become fistulous, the  extirpation of the hemorrhoidal tumors accom-
 plishes  likewise the cure of the  abscess.   When, however,  piles
 are attended with a chronic  mucous discharge, this may be checked,
 or even completely cured, by cold astringent injections, the balsam
 of copaiba mixture, the sesquioxideof iron, a blister kept open over
 the sacrum, the cold bath, sea bathing, and exercise in the pure open
 air.

                        PROLAPSUS ANI,

 Though generally described as a descent either of the  mucous mem-
 brane alone, or of the mucous and  muscular coats together, seems
 to Sir Benjamin Brodie to be always of the latter description, the
 other case being merely  internal  piles, which  we  know are only
 covered  by the mucous  membrane.   He admits,  however, that
 protrusions of elongated portions of mucous membrane take place,
 but they are arranged by  him under the head of excresences and
 polypi.   On the other hand,  Mr.  Salmon* represents prolapsus of
 the rectum to  be always a descent of the mucous membrane, which
 is detached from the external coat; so that he differs from Sir B.
 Brodie in even a greater degree than the generality of other writers,
 who describe  two forms  of polapsus, one  with descent of the
mucous coat  alone, the other with prolapsus of  both.
  Prolapsus ani is more common in infancy and  old age, that any
other period  of life.   It  is  particularly  frequent in children with
large tumid bellies, and confined  bowels, where the whole mass of
intestines becomes too large for the abdominal cavity.  In children
also the prostate gland,  urethra,  and  vesiculae seminales are not so
much developed, and  the attachment of the rectum to the surround-
ing parts does not extend so high up as  in the  adult.   In grown-up
persons, prolapsus ani sometimes occurs as a consequence of piles.
In this case, the piles are  seen at the upper part of  the prolapsus,
close to the anus, forming a zone round  the gut; and the color and
appearance of the mucous membrane, covering the protruded piles,
is altogether different  from that of the membrane investing the rest-
 of the bowel.f
   Treatment.—Except when prolapsus ani takes place in a child
* F. Salmon, on Prolapsus of the Rectum, p. 6, &c.
t Sir B. Brodie, Lond Med. Gaz. 1834-35, p. 845. 
PROLAPSUS ANI.
301
from the irritation of calculus in  the bladder, when  of course the
cure will depend on the removal  of the stone, relief may generally
be derived from  Sir Benjamin  Brodie's plan: it consists in pre-
scribing occasionally calomel  and rhubarb, directing  that the child
may not eat much  vegetable  food, and  injecting  into the  rectum
every morning  two or three  ounces of  a lotion composed of tinct.
ferri chloridi  3j., aq. purae lbj.   When, in an adult, prolapsus ani
is a consequence of piles, the first indication is to extirpate the lat-
ter.
  The prolapsus consists, as I have stated, in a descent of the mu-
cous and muscular tunics of the rectum,  the upper portion of which
passes down  in  the manner of  an  intus-susception,   within the
lower as far as  the anus, or even  further, so  as to  protrude to the
extent of from one to several inches.   In general,  the prolapsus
occurs whenever the patient goes  to stool; but, in some individuals,
whenever they  continue long in the standing position.
   This  state  of the rectum  is often combined with hemorrhoidal
complaints, and a feeble, relaxed   constitution.  In certain  chronic
cases, where the prolapsus  has  existed a  long while, the mucous
coat becomes thickened and almost insensible; but, in most instan-
ces, the part is liable to attacks of inflammation, followed  by ulce-
ration.   The disease is frequently attended with discharge of blood,
mucus,  or even pus.  In the treatment  of other examples, present-
ing themselves  in the adult, the reduction of the  bowel  is the first
thing to which the surgeon naturally directs his attention.   In some
cases, this is easily accomplished; but  in others  difficulty is expe-
rienced, in consequence of the swelling of the parts, and the spinc-
ter strangulating the bowel.   In fact, the protruded portion of bowel
may be twice or thrice its natural size, of a deep purple red color,
marked with ecchymosis and sometimes in great danger of mortifying.
   Under these circumstances, the immediate reduction of the bowel
is urgently indicated.   The patient may lay on his face,  as Dupuy-
tren directs, with a pillow placed under the pelvis;  or he may sup-
port himself on his  knees and elbows in bed, with the nates towards
the surgeon.   The protruded part having  been covered with  wet
linen, and a  compress  laid  over its  extremity, pressure is to  be
gently made on its base, so as to diminish its bulk, while the same
part is gradually pushed within the spincter muscle.  Thus the re-
duction commences with the return of the portion of bowel last pro-
truded.    If this plan should not succeed, the effect of scarifications
and  leeches on the  part is sometimes tried, though such practice is
condemned  by Dupuytren.  Followed up  by cold  applications,
however, it answers in a few  examples.
   Even when the reduction  is accomplished, the condition of the
parts producing the tendency  to prolapsus yet remains, and, conse-
quently, the relief is only temporary.
  Cold astringent lotions and  the cold bath  are frequently employ*
   vol.  n.                   26 
302        DISEASES OF  THE ANUS AND RECTUM.

ed, for the purpose of giving strength  and tone  to the sphincter,
which may then make greater resistance to the descent of the bowel.
This practice occasionally  proves effectual, but not till it has been
persevered in for a great length of  time.   Where the  disease has
begun in early life, and continued  to the  adult  age, the  horizontal
posture, the use of a  bed-pan, an astringent injection daily, and a
course of Ward's paste, are the means recommended by Sir. Ben-
jamin Brodie, though he acknowledges that  they will not always
succeed.   Astringent lotions, and compression, made with a piece
of sponge, covered with fine  linen,  and supported with  a  T ban-
dage, sometimes answer in  children, but mostly  fail in adults and
old persons.
   Under  such circumstances,  the  excision of the whole circle  of
the protrusion, or of a part of it,  or  of any hemorrhoids on the
mucous membrane, is advised.  The risk of dangerous, and even
fatal, hemorrhage is the objection urged against these  proceedings
by Dupuytren.   If,  says  he, the cautery be used to  stop  the he-
morrhage, the agony, and chance of a perilous degree of inflamma-
tion being extended to the upper part of the  rectum and  neck of
the bladder, will yet form a prohibition to the practice.    The extir-
pation of  the protruded part, either  with  the  knife or the ligature,
must always be  out of the question, so long as the bowel admits of
being reduced.
   Instead of these measures, I should  prefer the  less severe expe-
dient,  originally suggested and practised by Hey,  and  adopted  by
Dupuytren; it consists in raising up two, three, or more of the ra-
diating folds of skin  close to the anus with a pair of forceps, furnish-
ed with broadish extremities, and removing them  with curved scis-
sors.   Afterwards, on cicatrisation taking place, the  anus becomes
lessened  in diameter, and the relaxed state  of the  skin removed.
The excision should  extend up close to the anus, and even half  an
inch within it,  if the relaxation be considerable.  The  number of
folds to be taken away is also to be greater in proportion to the de-
gree  of looseness  of the   skin near the anus.   Notwithstanding
the remark made by M.  Velpeau*,  that the  description of Hey's
practice,  in  the dictionary of Practical  Surgery, is so  imperfect,
that this  improvement  in  surgery would have "fallen into oblivion,
even  in England,  if it  had not been  for Dupuytren; the fact  is,
 that there are few British  surgeons, of  any experience, who have
not been  in the  habit of performing  Hey's operation  for  the  last
 thirty  years.  I have practised it in several instances with complete
 success.   Besides,  if the Dictionary were not in existence, English
 surgeons  possess Hey's  Practical  Observations  in Surgery,  con-
 taining his own explanations.  At the same time I fully admit the
* Nouveaux Elem. de M d. Operatiore, t. iii. p. 1002. 
   PRETERNATURAL  CONTRACTION OF  THE SPINCTER ANI.  303

merit of Dupuytren's more particular account of the subject.   Mr.
Salmon's  plan of removing  a triangular  portion  of the  sphincter
seems to  be  a modification of  Hey's  or  Dupuytren's  method.
Many years ago, I performed this operation on a Jew, carrying on
the trade of a furrier in Holborn; and last year (1838), I adopted
it in University College Hospital, for a little boy,  about four years
old, who had suffered from  a prolapsus  ani almost from birth, and
for which  the plan advised by Sir Benjamin Brodie, after a long
and strict  trial, was found unavailing.   The removal of two slips of
integument was followed by a complete cure.

    PRETERNATURAL CONTRACTION OF  THE  SPHINCTER  ANI.

   When the sphincter  has  been long  in a state of spasmodic con-
traction, it undergoes  considerable enlargement,  and acts with  a
proportionable increase of power.   The  disease is chiefly met with
in women, especially those who are disposed to hysteria; but some-
times also in men.   In emptying the rectum, the patient is  obliged
to strain very much, particularly when  the feces are  hard, or even
solid.   Mr. Salmon even conceives, that this  condition sometimes
leads to prolapsus of the rectum; though a close state of the sphinc-
ter appears, I  think, more likely to be  an  obstacle to any descent
of that bowel.    There  is pain not only while  the feces are pass-
ing, but for a long time afterwards.  Frequently the disease is com-
plicated with a small, but exceedingly  sensitive,  ulcer of the  mu-
cous membrane, or with irregular cracks  or fissures, which M. Vel-
peau suspects  may often be the cause of the spasmodic affection of
the spincter.
   Treatment.—Relief may be  derived from aperients: which  will
keep the feces from  being of a hard or solid  consistence.   A sup-
pository of extract of belladonna has  been tried by Sir  Benjamin
Brodie; but as it is apt to produce deleterious effects on  the brain,
he does not at present frequently resort  to  it.   Another  plan  ad-
verted to by him, and also by Mr. Salmon,  is that of always dilat-
ing the anus with a bougie before the patient goes to the water-closet;
a plan that must  be attended with extreme annoyance.   In obsti-
nate cases, it is necessary to divide one side of the sphincter mus-
cle.   The pressure of the finger, or a  plug  of lint, will command
the hemorrhage.  An active purgative  should be given the day  be-
fore the operation, and  opium afterwards to keep the bowels con-
stipated for two or  three days, so that the  wound may not be dis-
turbed.  It is to be dressed  with lint,  and generally heals in about
three  weeks.   If the surgeon avoid dividing the sphincter muscle in
the  female forwards,  no inconvenience results from the operation,
the  patient retaining the feces after it as well as ever. 
304         DISEASES OF  THE  ANUS AND RECTUM.
        ULCER WITHIN THE  RECTUM  OR  FISSURA  ANI.

  The ulcer,  which sometimes accompanies a spasmodic contrac-
tion of the  sphincter, may take place independently of it, on  the
posterior part of the  rectum,  opposite to the point of  the os coc-
cygis.  It occurs principally in  costive individuals, is difficult to heal,
disposed to enlarge, and creates a great deal of pain during and after
each passage of the feces.   In some instances, it bleeds copiously.
   Treatment.—Mr. Copeland's practice is  to  divide  the mucous
membrane longitudinally, so as to  comprise  the  ulcer in the inci-
sion.   According to Sir Benjamin Brodie, a cure may always be
accomplished by dividing the  spincter muscle, and  very often with-
out an operation of any kind, if the confect. pip. comp., or Ward's
paste, be given internally, and the  bowels  kept open with lenitive
electuary and sulphur.  Ward's paste,  blended  with soap, he has
also introduced into the rectum, as a suppository, twice a day, with
advantage.

                 STRICTURE  OF  THE  RECTUM

Consists of  a thickening and induration of the mucous and muscu-
lar textures, and no doubt also in similar changes of the interven-
ing cellular  tissue.   Sometimes the  contraction extends three or
four inches up the bowel; but, in other  instances,  the constriction
is limited to a very narrow circle.   Very often the  gut is of its  nat-
ural diameter close to the anus; but,  about an  inch and  a half, or
two inches above it, there is a circular contraction, while higher up
the bowel  is  again of its natural  diameter.  Now, although the
stricture is thus confined to a certain extent of the  rectum, the mu-
cous membrane is in an unhealthy  state  both above and below the
contraction.*
   The disease occurs in both sexes, but in adults  more frequently
than children, and comes on very  gradually.   At first, the  patient
experiences some  slight difficulty  in emptying  the bowel,  and is
obliged to strain a good deal, especially if the feces be hard, which*
when discharged,  are found to be of small  diameter.   At  length,
the constricted portion of the  bowel inflames, and the pain then be-
comes much more  severe, attended with a  discharge,  not only of
mucus, but  of blood and purulent matter.   If the  disease proceed
further,  inflammation  takes place in  the cellular tissue round the
rectum,  and putrid abscesses form, which burst in various places
near the anus, and  occasionally into the urethra  in men, or  vagina
in women.  I lately  attended a  gentleman,  from whom nearly a
pint of matter issued from the rectum daily for some time before he
* Sir B. Brodie, in Lond. Med. Gaz. 1834-35, p. 23. 
STRICTURE  OF THE  RECTUM.             305
died, and there was pus under the glutaei muscles.   In some instan-
ces, the patient dies with symptoms like those of stragulated hernia,
in consequence  of the  stricture becoming  completely blocked up
by indurated feces.  Great pain  in the abdomen,  vomiting, and a
tympanitic  distension of the belly, are here amongst the most promi-
nent symptoms.   As Sir B. Brodie has explained, the bougie and
injections may remove this  kind of obstruction once or twice, and
thus save  the  patient;  but another attack  coming  on, the treat-
ment may  not be equally successful.   In the advanced  stage of the
disease, patients generally become completely hectic, but often lin-
ger many years.
   Most of the  strictures of the rectum met with by Mr. Salmon, he
says, were situated between five and six inches from the anus; but
many other surgeons, amongst whom is Sir  Benjamin  Brodie,  rep-
resent the  lower part of the rectum as their  common situation.   At
all events,  they occur high up in a certain proportion of cases, and
even in the sigmoid flexture of the  colon.
   The treatment consists  in the  occasional  employment of mild
aperient medicines and injections;  sometimes in the introduction of
a suppository of opium, or hyosciamus,  and in dilating the stric-
 ture with  bougies.  The  exact place and  degree of the stricture
should first be ascertained, if possible, with the finger; and if the dis-
ease be not in too irritable a state,  the use  of the bougie may com-
 mence at once.   The instrument should be kept in ten minutes, a
quarter of  an hour, or longer, every  day, or  every other  day, ac-
 cording as the  patient may be able to bear it without too much in-
 convenience.   Mr. Salmon considers that  it is better  to pass the
bougie less frequently than  usually  recommended, and  at  intervals
 of from three to five days.   In some cases, Sir B.  Brodie divides
 the stricture in two or three places  with a bistoire cache, so adjusted
 that the blade may be opened  to about one sixth  or one fourth of
 an inch.   The incisions having been  made, the larger bougie can
 be at once introduced.
   Frequently  this disease is  attended with such  irritation  of the
 bowel, that bougies cannot be resorted to, unless  this condition be
 first obviated by other means.   A  suppository  of opium, or hyos-
 ciamus, at night,  followed  by a mild aperient in  the morning, will
 sometimes enable the patient  to  bear the use  of the   bougie.  In
 other instances, a draught, composed of half a drachm of balsam
 of copaiba, fifteen minims of liquor potassae, three drachms of mu-
 cilage of gum arabic, and nine drachms of carraway water, taken
 thrice a day,  has  answered the purpose.*   When  the  feces accu-
 mulate above the  stricture, and cause considerable irritation by dis-
 tending the bowel, an elastic gum  catheter should be  introduced
* Sir B. Brodie, Op. cit. p. 29.
        26* 
306         DISEASES OF  THE  ANUS AND RECTUM.
through the stricture, and tepid soap and  water injected,  followed
by warm water.  By persevering in this  plan  every  day, or every
other day,  the whole collection will soon be cleared away.
   If the disease be much  advanced, the mucous membrane ulcer-
ated, and abscesses have formed, the case will  rarely admit of com-
plete cure.
   I fully concur with Sir Benjamin Brodie, that bougies are scarce-
ly ever, perhaps  never, safe  for strictures of the rectum, except
when the obstruction is within reach of the finger.

           MALIGNANT DISEASES  OF  THE  RECTUM

Rarely occur till after the middle period of life.   At first, the pa-
tient experiences some slight uneasiness about  the  bowel, followed
after a time by difficulty of expelling the feces, which gradually in-
creases, and becomes attended with acute lancinating pains, extend-
ing through the pelvis to the back, nates,  hips, and  thighs.   Fre-
quently, these pains are followed by a sudden gush of a fetid bloody
discharge from  the bowel, in consequence of ulceration having ta-
ken place.   At length,  the stomach gets out of order, and the gen-
eral health  declines.   The patient has a sallow look, denoting the
existence of a severe organic  disease; and frequently the scirrhous
or medullary affection of the rectum is accompanied  by  other vis-
ceral  disease.  Sometimes, but not commonly,  in the  advanced
stage, there is copious hemorrhage.from  the bowel; and  abscesses
form around the part, and burst externally.   In females, they burst
into the vagina; and the ulcerated communication between this tube
and the gut may be so free, that  a large  quantity of  feces may be
discharged through the former passage.   In  the male sex, the ul-
ceration frequently makes a  communication between  the  rectum
and bladder,  or the rectum and  the urethra,  and  then  the patient
expels not  only air,  but feces, with the urine.  Retention of urine
is another frequent  complication  of the present disease.   The pa-
tient after  lingering a considerable time in severe agony, is  at last
exhausted.   In some instances, the diseased mass completely ob-
structs the  passage of the feces, and symptoms, resembling those of
strangulated  hernia, come on; or the bowel ulcerates immediately
above the obstruction, and the feces, escaping into the cavity of the
peritoneum, excite a fatal attack of peritonitis.*
   Whether the disease  partake  of the character of carcinoma, or
of medullary disease, it consists in  the growth  of a new substance,
whose pressure seems to produce an absorption of the mucous and
muscular coats of the bowel.f   The cases, in  which  the mass pro-
jects into the bladder, or vagina,  are, no doubt, examples of medul-
* Sir B. Brodie, in Lond. Med. Gaz. 1834-35, p. 238.
I" F. Salom, on Stricture of the Rectum, p. 63. 
FRACTURES OF THE OSSA NASI.
307
lary  cancer,  or  fungous  haematodes.    In some  examples, the
texture of the morbid parts is such,  that it  appears like a combina-
tion of scirrhus and fungous haematodes,  some portions of  it being
of a soft medullary consistence, and others  hard.
  Attempts have  been made to remove malignant disease of the low-
er part of the rectum with the knife.   If ever such an operation be
justifiable, as Sir Benjamin Brodie observes, it must be where the
disease  is very  low down, and quite  in its earliest stage.   Under
other circumstances,  there would be no probability of the whole of
the  diseased  textures being taken away.
  Bougies render the disease worse.   Opiate clysters, and injec-
tions  of  linseed  oil,  with or without  lime water, sometimes allay
the pain  and  irritation.   Sir Benjamin Brodie speaks  favorably of
the liquor potassse  andbalsam  of copaiba, as internal medicines.
The  sufferings of  the patient always  make the exhibition  of ano-
dynes indispensable,  and the best are  the  acetate and muriate  of
morphia.
             PARTICULAR  FRACTURES.

               FRACTURES  OF  THE OSSA  NASI

Are by no means unfrequent, a circumstance accounted for by the
prominence which  these bones form,  and  their being so little pro-
tected by the soft parts.   The injury can only happen from direct
external violence, as blows, or falls on the face.   Besides being ac-
companied by evident marks of contusion,  there is bleeding from the
nose;  and in consequence  of the movable state  of the pieces  of
bone,  a crepitus can be felt.   In  some instances, the fragments are
not at all displaced; but  in  others,  where the  force  applied  has
been greater, the ossa nasi are driven  inwards towards the nasal fos-
sae, and, if there has been time for much  swelling of the soft parts
to come on, the injury and depression of the bone  is  to be ascer-
tained by manual  examination;  for  the  tumefaction  will conceal
from the  eye the nature of the accident.   Sometimes, the fracture
extends through the nasal process  of the upper jaw-bone*, and across
the nasal duct,  attended with  a great deal of ecchymosis, a regur-
gitation of blood from the lachrymal  puncta,  and  an impediment to
  * Such a case was under the the care of my friend, Mr. Hooper, about three years
ago.  The  injury was produced by  a scrubbing-brush being thrown in  the patient'a
face with immense force.  There was likewise injury of the brain.  The case  soon
ended fatally. 
308
PARTICULAR FRACTURES.
the passage of the tears  into the nose.  Lastly, the  violence may
be transmitted through the perpendicular plate of the ethmoid bone
to its  cribriform plate,  which  may also break, and  symptoms of
pressure, or injury of the  brain, be excited.  In  other  instances,
there may be no fracture of the cribriform plate, yet the brain suffer
concussion.
   When a fracture of the nasal bones is not attended with displace-
ment, all that  is requisite to be done is to apply the cold evaporat-
ting lotion; but, if the fragments are  beaten inwards, they should
be restored to their proper situation,  by introducing  a director up
the nostril, and adjusting the pieces of bone with the aid  of the fin-
gers applied externally.
   Generally, when the fragments are replaced, they have no dispo-
sition to quit  their situation again;  but,  cases are  mentioned, in
which it was judged necessary to afford  some support, by means of
lint passed up the nostril.  When the soft parts are much swollen,
bleeding, leeches, and other antiphlogistic means  are  indicated.

FRACTURES  OF  THE  MALAR AND SUPERIOR MAXILLARY  BONES

Are rarely met with,  except as the effect of gunshot violence, or
other  great mechanical  force applied directly to the face.  Thus,
the cheek-bone is sometimes fractured by the  kick of a  horse, or
the blow of a hammer; under  these circumstances, there must be
more or less splintering of the bone, and contusion, or even lacera-
tion of the soft parts.
   Individuals sometimes  attempt suicide by firing a  pistol into the
mouth.  In such cases,  the alveolary processes, with the teeth, are
often forced away,  together with the palatine processes of the up-
per maxillary bones, the  palate  bones, the lower  turbinated bones,
the vomer, and lateral portions of the ethmoid bone.   The antrum
is of course laid open.   In one case, recorded by Dupuytren, the
patient lived till the fortieth  day; and  after death, the cribriform
plate of the ethmoid bone was found fractured, and a bullet lodged
in one of the anterior lobes of the brain.
   All action of the muscles about the throat is to be suspended,
and only liquid nourishment given with a spoon, or injected through
an elastic gum catheter, passed from the right nostril into the  pha-
rynx.  Displaced portios ef the palate are  to be reduced;  splinters
of bone removed;  and any injurious effects .on the  brain  counter-
acted according to the rules,  delivered  in the observations on In-
juries of the Head.   The soft parts are to be rectified  as well as
possible.   Antiphlogistic remedies,  inclusive  of bleeding, will be
indispensable.

             FRACTURES  OF  THE  LOWER JAW-BONE

 May take place  in its body, its rami, the coronoid process,  or the 
           FRACTURES  OF THE LOWER JAW-BONE.        309

neck of one of its condyles.   A fracture  sometimes  occurs  near
the chin, though rarely in the  precise  situation  of the  symphysis,
generally at some point between the symphysis of the bone and the
insertion of the masseter muscle.  From this insertion, as far  back
as the angle of the jaw, or root of the coronoid  process, the  bone
is covered externally by the masseter, and inwardly by  the internal
pterygoid muscle, a circumstance explaining the diminished frequen-
cy of fractures in this particular portion of the  bone.   It explains
also another fact, which is, that when fractures  do  happen  in  this
situation, they are not very liable to displacement, because the  fore-
going muscles antagonise one another.
   The lower jaw-bone may be broken in two places at once, name-
ly, on each side of the symphysis, and, in  this case, it is difficult to
keep the middle piece in its right  situation, because  several  mus-
cles, concerned in depressing the jaw, are attached to that  part of
it, and draw it downwards and backwards.
   Fractures of the lower  jaw may  be perpendicular, oblique, or
transverse, that is, parallel to the base of the bone.   These last arc
less common  than perpendicular and oblique fractures; but,  they
are occasionally met with, detaching a portion of the alveolary pro-
cess, with  the teeth  in it, from the rest of the bone.
   Fractures of the lower jaw  are sometimes comminuted, the  bone
being broken in several,  or even many, pieces.   When  the fracture
is near the chin, whether the bone  be broken on one side or both,
the  fragment comprehending  the symphysis  is drawn downwards
and backwards towards the os hyoides  by the action of the digas-
tricus, mylo-hyoideus, genio-hyoideus, and genio-hyoglossus.
   Fractures of the ramus  are  not very common, because this part
is protected by the zygoma and masseter.   Fractures  of the  neck
of the condyle are  more  frequent than those of the  coronoid  pro-
cess;  and the condyle itself may then be drawn forwards and dis-
placed by  the action of the external pterygoid muscle.   When the
ramus is fractured, the fibres of the masseter and internal pterygoid,
being attached to  both pieces,  prevent any considerable displace-
ment.
   When a fracture of the lower jaw is accompanied  by displace-
ment, the nature of the accident is readily detected by the inequality
in the line  of the base of the jaw; by an irregularity in the arch of the
 teeth; by  the  inclination of the mouth more to one  side than the
 other; and by the crepitus, plainly distinguishable  by manual exam-
 ination.   When the gums are lacerated, or the injured portion of
 the bone is exposed  by  a  wound, as  is often the  case,  forming  a
compound fracture, the  nature of the accident is still more ob-
vious.
   When the ramus, or the neck of  one of the condyles, is broken,
the patient will complain  of  severe pain in the ear; and when the
jaw is moved, a crepitus is perceptible. 
310
PARTICULAR FRACTURES.
   The reduction of a fracture of the lower  jaw is easily  accom-
plished by means of the thumbs introduced within the mouth, and
the fingers applied  externally to  the  base of  the  bone.  The sur-
geon is to draw the displaced fragment upwards,  and  a  little for-
wards, so as to bring it on a level with that fragment  which retains
its proper situation.   By attending to the line  which the base of the
jaw ought to form, and the regularity or irregularity of the  arch  of
the teeth, he  may  always judge  of the correctness  of the re-
duction.
   Easy  as  the  reduction is, the maintenance of it is  sometimes
troublesome, requiring that the  arch of the teeth in the broken bone
should be kept steadily applied to that of the teeth  in the upper jaw.
Hence, when the teeth are naturally irregular, or  accidentally defi-
cient, certain practitioners consider it advisable to  introduce a piece
of cork between such teeth as may be present, in order that  there
may be a smooth even surface, against which the lower jaw may be
confined.  Others inclose the fractured part of the jaw with paste-
board, which on its first application is to be softened with warm wa-
ter, so that it may adapt itself to  the shape of the  part.  Whether
pasteboard is used or not, the broken jaw is to be  well supported,
and kept steady with a roller, or, what is  much  better, the  four-
tailed string bandage, the centre of which is to be put on the chin,
and the front tails fastened over the occiput, and the posterior ones
over the forehead.   The assistance of a compress under the part
that has  a tendency to be drawn downwards and backwards, is fre-
quently required.  Mastication and conversation are to be avoided,
as causing disturbance of the fracture.  Hence only spoon victuals
should be allowed.   In bad compound cases, the  administration of
food and medicines through an elastic catheter is sometimes deemed
advisable.
   Fractures near the symphysis are very difficult  to keep right, on
account of the incessant disturbance of this part of the bone by the
muscles attached to it and  the  oshyoides;  viz. the digastricus, my-
lo-hyoideus, genio-hyoideus, and  genio-hyoglossus, all of which are
put in action in deglutition.   For this  case, Mr.  Lonsdale has in-
vented a simple, but ingenious instrument, which grasps the base of
the jaw and  the arch of the teeth, so as very effectually to maintain
the reduction.  Instruments, acting on a similar principle, have also
been suggested by various surgeons both in France and Germany.
They are not applicable to fractures of the ramus, coronoid  process,
or condyle.
   When  the neck  of the  condyle is broken, the condyle itself  is
drawn inwards and forwards by the action of the external pterygoid
muscle; and, as it cannot be replaced, we should  keep the neck of
the bone inclined towards it, by making the bandage act, particularly
on the angle of the jaw, with the aid of a compress. 
FRACTURES OF THE LOWER JAW.
311
  Cases are on record, in which  the detached  condyle,  instead of
uniting, was discharged from a subsequent abscess of the part.
   Sanson asserts, that  when the  coronoid  process is broken, the
fracture never unites; but that mastication is performed very well,
the masseter and pterogoid  muscles then fulfilling the  office of the
temporal.

         COMPOUND  FRACTURES  OF  THE  LOWER JAW

Are by no means uncommon; and, when it is remembered that this
bone  can only  be broken  by blows,  kicks, gunshot injury,  and
other  species of direct external violence, the fact is sufficiently ac-
counted for.  The same explanation enables us to understand why
the fracture  is also, in many instances,  comminuted, and several of
the teeth knocked  out, or loosened.
   The treatment  of a compound fracture consists  in removing all
loose  splinters of bone; reducing the fracture, if  attended with dis-
placement;  dressing the wound with simple  unirritating application;
applying the four-tailed  sling bandage   for the jaw;  giving all  food
with a spoon in a  liquid form, or, in  very  bad cast?s, through an
elastic gum  catheter,  passed  through  the nostril  into the  pharynx;
enjoining perfect quietude of the  part;  and adopting strict antiphlo-
gistic treatment.
   If  abscesses form, an early opening should be made in them, and
the mouth kept  clean with a common gargle, or one containing the
chloride of  sodium.   When necrosis takes place, the dead portions
of bone  should  be removed, as  soon  as exfoliation has  advanced
far enough.
   Fractures of the  lower  jaw  are sometimes  complicated  with
laceration of the artery or  nerve, in the canalis mentalis.  I  have
never seen  an instance, however, in which the bleeding did not
soon  stop, after  the reduction of  the fracture.
   As the lower jaw is a  particularly vascular bone, the repair of its
accidental injuries is  generally accomplished with surprising quick-
ness.   Hence, even the  worst fractures of it, compound and  com-
minuted ones, generally have a favorable termination.
   I have seen two or three horrible cases, in which nearly the whole
of  the lower jaw,  and the  integuments, and  the muscles connected
with itj and  more  or less of the  tongue, were shot  away; yet, the
patients  recovered,  and  in  a more expeditious manner than might
have  been expected.
   Instances are recorded, where fractures of the lower jaw continu-
ed united.   In one case of this  description, Dr.  Physic of New
York, succeeded  in bringing  about the union of the bone, by pass-
ing a  seton  between the  fragments. 
312
PARTICULAR FRACTURES.
                  FRACTURES OF THE SPINE.

  If we except the atlas, the tooth-like process of the dentata, and
the spinous processes of the vertebrae in general,  one of which may
be fractured  without any other injury  of the  spine, it  is not  usual
for a vertebra to be  broken singly.   Generally, the body of one
vertebra, and the articular or transverse processes, either of the ver-
tebra above or below that of which the body  is fractured, are like-
wise implicated.
  Fractures  of the spine, like those of the cranium, are important
and dangerous, not by reason  of the injury of the bones themselves
abstractedly conisdered, but on account of the effects produced on
the very essential  part of the nervous system, which the vertebrae
contain and protect.
  Fractures  of the spinous processes may not be accompanied  by
any injury of the spinal marrow;  but  those extending  through one
of the  bodies of the vertebrae, and the neighboring articular and
transverse processes, cannot happen, without  a degree of violence,
that never leaves the spinal cord entirely free from injury; and hence,
the accident brings on a train of dangerous symptoms, which, soon-
er or later, generally have a fatal  termination.
   When the  fracture is situated in the lower portion of the vertebral
column, it mostly produces loss both of sensibility and of motion in
the lower extremities, and paralysis of the bladder.   When the in-
jury is higher up, in addition to these  symptoms, the abdomen be-
comes  prodigiously distended with air collected in the bowels;  when
it is still higher, the intercostal and abdominal muscles are paralyz-
ed, and the breathing difficult, because only carried on by the dia-
phragm.
  When the lower cervical vertebrae are broken, and the medulla
hurt, the upper extremities, as well as the lower, are both paralyzed.
If the  injury be  situated above the fourth cervical vertebra, or the
origin  of the phrenic nerve, and, especially,  if there be  any dis-
placement of the fragments, or compression or injury of  the spinal
cord, respiration cannot go on, and immediate death is produced.
  Amongst the  symptoms of  fractures of the spine, priapism, and
even emission of the  semen, are   by no means uncommon.   Both
of them  were noticed in  a young man under my care, who  died
from a fracture of the cervical vertebrae in University College  Hos-
pital, in October, 1835.
  Such  are  the consequences usually  induced, when a fracture of
the spine is accompanied  by displacement of the  fragments, and
with more or less compression,  or injury,   of the corresponding
portion of the spinal cord.
  On  dissection, the spinous process of the  displaced vertebra  is
found depressed; the body of the bone broken through; and a part 
FRACTURES  OF THE SPINE.
313
of it thrown more or less forwards or to one side.   A displacement
from laceration of the intervertebral substance is very rare.  Some-
times blood is extravasated between the vertebral  canal and  the
sheath of the  spinal  cord,  and sometimes on the latter part itself.
In slight displacements, the medulla is compressed and bruised; in
more considerable ones, it  is generally torn  through; but the dura
mater usually  remains entire.
   With respect to  the symptoms  of a  fracture of the vertebral
column,  many of them,  and indeed  the most  dangerous of them,
may  be  brought on  by a  violent  concussion of the spinal cord.
Hence, the diagnosis is sometimes obscure.   An inequality in  the
line of the spinous  processes, a crepitus, and  even deformity,  are
occasionally perceptible;  and these circumstances, joined with  the
extent of the paralytic disorder, according  to the  situation  of  the
injury, as already explained, will leave no doubt about the nature of
the accident.
   In consequence of the paralysis of the bladder and sphincter ani,
the patient cannot void his urine, and the feces come away involun-
tarily.   The  qualities of the  urine,  also,  undergo  a remarkable
change;  for it becomes strongly impregnated with ammonia.  It is
likewise found, that when the patient continues to live a considerable
time, with the urine in this state, the  bladder itself becomes thick-
ened, softened, and  even ulcerated.   The  evacuations  from  the
bowels are often remarkably dark and fetid.
   Patients,  who lie for weeks and months in  a  paralytic state  from
injury of the spine, are much  exposed to risk of sloughing of the nates.
Sir Astley Cooper mentions a case of fracture of the lumbar verte-
brae, where  the  patient lived two  years, and  then  died of such
sloughing.
   A fracture of the spine is capable of union, just like fractures of
other bones.   If the patient get over the  danger, arising from  the
injury of the spinal  cord, the  fracture itself is  certainly capable of
reparation.
   The chances of recovery and the length of time the patient may
live after the accident, when a final recovery does not ensue, depend
materially upon the  situation of the fracture,  and its degree of dis-
placement; or, in other  words, upon  whether the fracture affects
the cervical, dorsal, or lumbar vertebra?, and whether the  spinal
cord is contused, crushed, or otherwise wounded.  The higher  the
fracture,  the sooner does it generally  prove fatal.
   When the dorsal  vertebrae are broken and  displaced, the patient
seldom lives beyond two  or three  weeks; but Sir Astley Cooper
knew of  one instance in which the patient lived nine months.
   When the lumbar vertebrae are fractured,  the patient often lives
a month  or six  weeks; but he may live a considerable  time, and
ultimately perish of sloughing of the  nates, or  mortification of the
   vol.  n.                   27 
314
PARTICULAR fractures.
lower extremities, as  happened in one  of the cases recorded by
Soemmerring.
   When the fracture  is in the lower cervical vertebrae, and attended
with displacement of  the  fragments, and  consequent injury of the
medulla, the patient rarely lives beyond the tenth day, death taking
place sooner the higher the fracture is situated.
   Fractures of the cervical vertebrae, involving one of the transverse
processes, are attended with  one  danger not occurring  in fractures
of other vertebrae, viz. laceration of the vertebral  arteries.   It is
the simultaneous injury of the spinal cord that is the principal source
of danger, and a fracture of any part  of the spine, if it were not
for this circumstance, would be repaired like other fractures, and the
patient recover.  This is proved by many recoveries, known to have
followed even  fractures of the  upper cervical vertebrae, where no
material contusion or  compression of the  medulla  had taken place.
   Sir  Astley Cooper mentions a  case that occurred  in  Mr. Cline's
practice, where the first  vertebra of the neck was  broken  across,
without occasioning death till a twelvemonth  afterwards, when the
fatal event arose from the dentiform process losing its support  and
becoming displaced.
   In the museum  of  the  College of Surgeons is a remarkable  pre-
paration, proving the  possibility  of a person living  a twelvemonth
after a fracture of the last dorsal vertebra, during which time nature
had made the greatest efforts to  bring about  a cure.   The patient
was kept perfectly at  rest, and  the urine at first  regularly drawn off
with a catheter; but,  by  degrees, a power of emptying  the  bladder
by the action of the abdominal muscles was regained,  and the patient
even became well enough to  sit up and to creep  slowly down stairs,
notwithstanding the lower extremities were completely deprived  of
all power of voluntary motion.  After death, the fracture was found
completely united by  bone.   The greatest  curiosity about the  case
is, that a fragment of  the body  of the vertebra had  been forced  at
the time of the accident  completely across the  vertebral canal,  so
as to divide the medulla spinalis,  the ends of which,  as  exhibited  in
the preparation, are an inch asunder.
   Soemmerring relates an instance, in  which the patient lived six
months after a fracture of the  body of  the first  lumbar vertebra,
and of the oblique and transverse  process of the last  dorsal  one.
After death, the  fracture was  found perfectly united  by  osseous
matter.
   In  one  of Cruveilhier's  engravings,  is  the representation  of a
fracture of the second lumbar vertebra, attended  with displacement.
The patient recovered from  paralysis of the  lower limbs,  and all
other ill consequences of the accident, but  died of another disease
four years  afterwards.  The greater part of  the  broken  vertebra
was pushed towards the left side and backwards; but the rest of it,
comprehending the right  articular and transverse  processes, and the 
FRACTURES OF THE SPINE.
315
 portion of the  body connected with them, remained  in its  natural
 situation.  The left oblique and transverse processes  were fractur-
 ed;  bony matter bad been thrown out for the repair of the injury—
 not from the fragments themselves, but, as/Cruveilhier states, rather
 from the vessels of the surrounding parts, the cellular and  fibrous
 tissues, and the muscles.
   In the case recorded  by  Mr.  Barlow (vol.  xvii. Med. Chir.
 Trans.), consisting of a fracture of the first lumbar vertebra,  sensa-
 tion began to return in the legs and  thighs after eight months, and
 the patient could raise himself in bed, and in twelve months could
 bear to be drawn out in a small chaise.   After an attack  of fever,
 sphacelation of the heel took place, pus was  voided with the urine,
 and gangrene commenced  over  the sacrum, of which  the  patient
 died.   The upper portion of the  spine was found to be  thrown for-
 wards,  and connected to the fore and  upper part of  the inferior
 fragment by callus.  The articular processes  of the first lumbar and
 last dorsal vertebrae were dislocated, the vertebral  canal was lessen-
 ed in diameter  to one half of its  natural  extent, pus  was found in
 the pelvis of each kidney, and the bladder was diseased.
   Mr.  Lawrence  mentions a case of fractured  spine, where the
 patient lived a considerable  time after the accident, and at  length
 died, when the fracture was found  soldered together  by bone; but
 the osseous matter had so nearly  filled up the vertebral canal, that
 there was only just  room enough in it for the  end of a blowpipe.
 The spinal cord had been completely divided.
   With respect to the treatment,  we are first  to consider what ought
 to be done when there  is no displacement.   Here the indications
 would be to draw off the urine once or twice a  day with a catheter,
 and  to keep  off inflammation of the spinal cord and  its sheath by
 antiphlogistic  treatment, especially by  bleeding,  active  aperient
 medicines, and perfect quietude in  the recumbent position.
   In a case of fracture with displacement, where  the patient is not
 quickly destroyed  by the extension of the paralysis  to the diaphragm,
 and other important organs, or by the case being  complicated with
 rupture  of the kidneys, spleen, and internal   hemorrhage, ought we
 to attempt to reduce the fractured  vertebrae,  as the only chance of
 removing the pressure from  the spinal cord?  Now, experience has
 little to  adduce in favor of  such  attempts, which  have  been made
 from time to time, but generally in vain.   In a patient, from  whom
 a  specimen  in the museum of University College was taken, the
 attempt was made, but to no purpose.  In the case recorded by Mr.
 Barlow, of Wriltle, it was also made; not with any bad consequences,
 indeed,  but without success, as on dissection  the fracture was found
 united, but in a state of displacement.   The  reduction had  not in
reality been accomplished, or, if accomplished, had not been  main-
tained.   In  making  the  experiment, there must  be some  risk of
rendering things worse, so imperfectly must we always be acquainted 
316
particular fractures.
with the exact position of the fragments.   But, even  if the reduc-
tion were accomplished, and could be maintained, the injury, which
the spinal cord has received, will yet  remain, and all the bad con-
sequences of it continue.
   The notion of removing pressure from the spinal cord, as is done
from the brain, by means of the trephine, led to the scheme of cut-
ting away the spinous processes and  adjoining  bony arches in the
situation  of the injury with Hey's saws;  an operation which, I be-
lieve, with Sir Charles Bell, would general!} of itself destroy  all
possibility of the  patient's recovery.
   Neither would  the removal of such  portion of the  vertebral col-
umn make any difference in the injury  of the  medulla  already exist-
ing, unless, indeed, it were an augmentation of it; nor could it alter
the position of the fragments of the body of  the broken bone.
   My views  would therefore restrict the treatment to means calcu-
lated  to lessen the risk of inflammation and suppuration of the med-
ulla, especially common antiphlogistic  treatment, including rest in
the recumbent  posture.   The urine should be drawn off once or
twice a  day with  a catheter, which  in these cases should not be left
in the bladder, as the beak of it is apt  to produce inflammation and
ulceration of that organ, followed by effusion of urine and peritoni-
tis.   The bowels are to be  regulated  with castor or croton oil.  If
possible, the  convenience and comfort of a fracture-bed should  be
afforded; and when there is a  tendency  to sloughing of the nates,
the hydrostatic bed should be employed.
   Should life continue long enough to justify the inference that the
fracture is united, though some of the  paralytic  effects of the acci-
dent still remain, we  might  try  the  effect of iodine  liniments, blis-
ters, the moxa, or issues.   The internal  and  external use  of strych-
nine has  been suggested; but I  know of  no facts in its favor.
   Very  curious effects are sometimes exemplified in  injuries and
diseases  of the spine,  which are referrible to the double roots of the
spinal nerves; the anterior of which are for voluntary motion, the
posterior for  sensation.   Thus, a few years ago, I attended a man
in'Black-Horse Yard, Rathbone Place, who was paralytic in both
lower extremities, in  consequence of a blow on the spine, received
in a fall from the mast of a ship; one  limb having lost all feeling,
the other all  sensation.   In fractures of the cervical vertebrae, below
the fourth, the arms are paralytic, but  one may be more so than the
other; and lately  in University  College  Hospital, I  had a  patient
with fracture of the fifth cervical vertebra, with  displacement, and
of the arch of the fourth without it, who had no power of action in
any of the muscles of the upper extremities, yet he possessed feel-
ing in these limbs down to the elbow.

                 FRACTURES  OF  THE STERNUM

Are less frequent than might be expected, considering its exposed 
FRACTURES OF THE STERNUM.
317
situation in front of the chest.   For this fact, there seem to be two
reasons; the first is, that  the sternum is a spongy bone, less brittle
than many others; the second  is, that  it  rests  on the cartilages of
the ribs, which form so elastic a support for it, that it is enabled to
elude any common violence by the yielding of those parts.   How-
ever, notwithstanding these circumstances, it  is sometimes broken.
In the course of the last five years, we  have had in University Col-
lege Hospital several examples of fracture of the sternum.   It may-
be fractured  by gun-shot violence, or by the passage of a heavy car-
riage over the trunk, or by any other considerable force applied  di-
rectly to the sternum.  But the fracture may occur in another man-
ner, which would not be expected.  M. David, in his Meinoire sur
les Contrecoups, relates a case, which  took place in the following
way: a bricklayer fell from the top of a house, and as  he was fall-
ing, the middle of his back struck against a piece of timber, and  the
consequence of this blow  was a  fracture of the sternum.   Now,  the
explanation  given  by  M. David of the mode  in which the sternum
happened to suffer injury, is, that it was broken by the violent action
of the abdominal muscles, diaphragm, and muscles of the neck, con-
nected with this bone, whereby  it was powerfully drawn at once in
different directions.   The truth of this account is confirmed by  the
curious fact, that the sternum is sometimes fractured during parturi-
tion by the violent efforts  of the muscles attached to it; for cases
of  this kind are  upon record.
   A fracture of the sternum is not  in itself dangerous; but  it may
be  followed   by  severe and even fatal consequences, on account of
the thoracic viscera happening to be injured at the same time: thus,
the lungs or the heart may be penetrated by a fragment of a broken
sternum.  In the Museum of University College, is a preparation,
exhibiting a  laceration of the right ventricle of the heart  by a portion
of fractured sternum.  M. Sanson met with a similar case, in which
the heart was torn by a sharp spicula of a broken sternum.   Blood
may also be copiously effused  in  the cellular tissue  of  the anterior
mediastinum; and  sometimes considerable inflammation  of this tex-
ture will ensue, leading to the formation of abscesses, and to various
degrees of necrosis in the injured bone.  One occasional complica-
tion of a fracture of the sternum is emphysema, or an  inflation of a
great part, or of the whole, of the cellular tissue of the body, which
can only take place, however, when a spicular of bone  happens  to
wound the lungs.
   As the sternum is a superficial bone, its fractures are readily de-
tected if there be displacement, the lower portion is generally  sit-
uated in front of the upper one, and sometimes overlaps it.  In most
instances, a crepitus is perceptible, produced  by the motion of  the
fragments on one  another  in respiration, and  particularly obvious
when  the patient coughs, if the surgeon's hand be applied  to  the
front of the chest.   The  patient, indeed,  is  usually teased  with a
                            27* 
'318
PARTICULAR FRACTURES.
frequent dry cough, and when the lungs have been pierced by a spi-
cula of bone, there is a spitting of blood, which may be followed by
emphysema.   The cough is particularly annoying, from the motion
and disturbance it causes of the injured part.
  If there be no displacement of the fracture, no complication, the
principal indication is to keep the fragments as  quietly as possible
in their present position, which is most effectually accomplished by
applying a broad  roller round the chest, and  making it press  on the
broken bone  and ribs, so as to limit and diminish  their motion. The
bandage  should  be rather tight, and kept from  slipping down  by
passing a  piece of tape over each shoulder, from the centre of the
roller behind  to a point in  front of the chest.   If the tapes were
fastened  too near the axillae, they would slip  off the shoulder, and
not answer the purpose of their application.   In order to  keep the
fragments as  quiet as possible, the trunk should be inclined forwards
and the pelvis raised, so as  to relax the abdominal muscles. When-
ever the sternum is broken, another indication is  to bleed the patient
freely, because the risk of inflammation in the chest must be guard-
ed  against.   Bleeding is  also one of the most  effectual means  of
relieving the  cough, which always occasions severe pain, and a great
deal of disturbance of the injired part.   The lancet, antiphlogistic
measures in general, especially quietude,  the application of a broad
bandage  round the  thorax,  the relaxation of the recti abdominis,
and the administration of an emulsion with a little opium, for  the
palliation  of the cough,  may be  said to constitute  the  principal
means of treatment.
  But, supposing the fracture were attended with displacement, some
practitioners advise us to relax the abdominal muscles, asserting that
we shall then more easily succeed in reducing the fracture by pres-
sure; while others  say it is  best to extend  the spine by  putting a
bolster under the loins, as  they assure us, that, in this position of
the patient, the  fragments can be more  readily  reduced.   Now, if
we were  unable to effect a reduction by these or other  plans, then
the question  would present  itself, whether we ought to  perform an
operation for the purpose of bringing about a coaptation of the bone?
Whether we should  be  justified in making an incision down to the
fracture,  and trying to raise the depressed  portion of bone to  its
proper level, by means of  an elevator?  Without pronouncing  an
unqualified condemnation of this scheme, I  may safely remark, that
before we think of putting  it in  execution, we  should be sure that
 the existing  bad symptoms  are really  produced by compression
 of the thoracic  viscera,  and that they are of a sufficiently  urgent
 nature.   A moderate depression of a portion of the sternum would
 not be likely to  create any dangerous symptoms, inasmuch as that
 bone lies over the anterior  mediastinum,  which merely contains cel-
 lular substance, pressure on which would certainly occasion no per-
 ilous consequences.   But,  we are also to recollect that the thoracic 
FRACTURES
OF  THE  RIBS.
319
viscera may be injured, and that such injury may be the true cause
of the urgent symptoms.   In this case, merely elevating  a moder-
ately depressed portion of  the sternum would  promise little  relief.
However,  what  I wish  to be  well considered is, whether the bad
symptoms are Droduced  by mere compression of the thoracic  vis-
cera,  or by any other description of mischief.   A case is recorded
by Petit, in which the patient recovered from an unreduced fracture
of the sternum, but experienced severe oppression in his chest, and
great  difficulty of breathing during the rest of his life.   It seems,
therefore, that, if the fragments are left displaced beyond a certain
degree,  the patient may suffer from the sternum being united  in this
deformed state.   The cases,  in which we might be called upon to
trephine the sternum (another proceeding fortunately  oftener spoken
of than  done), are, first, those in which purulent matter is confined
in the anterior mediastinum in considerable quantity, so as to occa-
sion dangerous oppression of the lungs;  and, secondly, others in
which it might be deemed right to adopt the practice to expedite
the removal of a  portion of dead bone.   But  even  circumstances
of this kind, truly requiring the operation, are  exceedingly rare, for
abscesses make their  way outward, and dead bone will in  time  sep-
arate  by the process of exfoliation.   The formal application  of the
trephine to the sternum,  for the purpose of raising a  depressed  por-
tion of it, I think, would hardly be deemed justifiable in the present
state of surgery.

                  FRACTURES OF THE  RIBS.

   The ribs are broken almost as frequently as any bones which can
be mentioned, except the clavicle and radius;  the middle ones being
those  which are most  exposed  to the accident, and  especially the
part of them near what is termed their  angle.   The  upper ribs are
rarely fractured, because they are protected in front by the clavicle,
and covered by the pectoral muscles; while behind they are shield-
ed, as it were, by the  scapula  and the  thick muscles of  the back.
As for  the lower  ribs, they   generally  escape,  in consequence of
their being so  short and moveable.  The  displacement of the frac-
ture can  only take place either inwards or outwards.  On account
of the connection of  those ribs, which  are  usually  broken, to the
sternum in front,  and  to the vertebrae behind, there can evidently be
no  displacement  in  the direction either  backwards or  forwards.
Neither can the  ends of the  fractured rib be thrown  upwards or
downwards,  because  the intercostal  muscles, which  are attached
equally to  both fragments, resist such  an occurrence.  However,
the ends of the fracture may be forced inwards, or they may incline
outwards; but, in by  far the  greater  number of instances, it is in
the direction inwards  that the  displacement happens.  The detec-
tion of a fracture of the ribs is not generally attended with difficul- 
320
PARTICULAR FRACTURES.
ty; for if we merely place our hand on the part that has been struck,
and desire the patient to cough, we can mostly perceive a crepitus;
or the natural  movements  of  respiration will render the same symp-
tom manifest,  if we merely press our hand upon the injured pari of
the chest.  However, when the ribs are broken towards their pos-
terior ends, under the thick  muscles of the back, we may experi-
ence a great deal more difficulty in detecting a crepitus.   When one
or more of the ribs are broken, the patient is annoyed with a sharp
pricking pain in the situation  of the injury, and has a frequent dry
cough, which, by the disturbance it occasions of the fracture, gives
considerable pain.   Now, supposing, we were not able to feel  the
crepitus, and  the diagnosis were obscure, we should then act  ac-
cording to the wise  maxim laid down by all the best writers on sur-
gery; namely, adopt  precisely the  same treatment as if the occur-
rence of fracture were a matter of  certainty.
   A  simple  fracture of one of the ribs, unattended  with  any par-
ticular complication, such  as  a wound of the lungs, emphysema, or
effusion of blood in the chest, is not productive of any serious dan-
ger,  and  generally has a favorable termination.  But  when  several
ribs are broken, and blood is extravasated in the chest,  or  the lungs
are wounded,  the accident often has a fatal result.  We hear almost
every day of cases, in which several ribs are broken by the passage
of carriages over the chest, and the fracture complicated with injury
of the thoracic viscera, effusion  of blood in the thorax, or an ex-
tensive  inflation of the cellular tissue,  constituting what is termed
emphysema.
   When the  accident is free from the complications  which have
been specified, the  right treatment is obvious.  It  is  a rule when a
surgeon is called to a strong  young person, who has  broken one or
more of  the ribs,  to practice venesection.   This is  done with  the
view of diminishing  the risk  of inflammation  within the  chest, and
the chance of internal hemorrhage.   Then, another indication is to
keep the rib as free from motion as  possible.   We are to endeavor,
therefore, to  prevent the intercostal muscles from  taking part in  the
performance  of the  function of respiration, and try to make the  pa-
tient breathe  principally by means of  the diaphragm and abdominal
muscles.   For this purpose, a broad roller is firmly  applied to  the
chest; or a strong napkin, the two ends of which must  be brought
from behind forwards, and then laced  over the sternum.   The  pa-
tient is thus enabled  conveniently to regulate  the tightness of  the
bandage himself, and, for the sake of his own comfort, he will be
sure to maintain the  requisite  degree  of pressure; for, when  the
roller becomes too  slack, he begins immediately  to experience  the
pricking pain again, and his cough is more troublesome. It is evident,
that whether we employ  a broad roller, or a  napkin, it would  slip
down towards the loins, if the precaution were not taken  to attach
two pieces of tape to the  central part of it  near the  spine, each of 
FRACTURES  OF THE CLAVICLE.
321
which is  to be  carried over the nearest shoulder, and sewed to a
point of the bandage or napkin below the clavicle.   The  French
apply another tape under the perinaeum,  to prevent the roller from
slipping upwards, but  this  would only be necessary  in  very corpu-
lent subjects, and is rarely  or never made use of  in this country.
  Fractured ribs, not attended with the complications already notic-
ed, are generally treated with  great  success; and,  in  four or five
w^eeks, a firm  union takes place.   If  the patient be left entirely to
himself, without any kind of surgical  assistance,  a broken  rib will
also, for the most part, unite;  but in the museum of University Col-
lege, is a specimen of a fracture of six  ribs, where the fragments
are only connected  by a fibrous or ligamentous substance.   With-
out speaking positively, I should presume, that, in this  example,
no effectual means had  been adopted to keep the ribs  motionless
during the treatment.
  In old persons, the cartilages of the ribs  and the ensiform carti-
lage are frequently ossified; and when they  are in this state, they  are
liable to be broken.   The ensiform  cartilage has been known  not
merely to be fractured, but to be depressed, or  beaten  inwards,
so as to lacerate the diaphragm, and tear the liver.  The cartilages
in their natural state may also  be  ruptured; and, when this happens,
they do not unite by cartilage,  but by  osseous matter,  a bony clasp
being formed,  by which the  fragments  are  bound together.  The
treatment of the latter injuries  is the same as  that  ordinarily adopted
for fractures of the ribs.

                FRACTURES  OF THE CLAVICLE.

   The clavicle  is  perhaps  more frequently  broken than any other
bone in the  body;  and for this  there are  several reasons.   The  ac-
cident is of frequent occurrence, in consequence of the bone serv-
ing two  offices, which expose  it to the effects of violence  applied
either to the shoulder or arm; namely,  it  keeps  the  scapula  at a
proper distance from the sternum, and is, at the same  time, a point
of support for the humerus, every impulse communicated to which
bone is transmitted  to it.   In  addition to these considerations,  it is
to be recollected,  that the superficial situation of the clavicle  in
front of the shoulder,  across the upper part of  the chest, must  ex-
pose it to injuries from blows,  the  fall of brickbats,  or other vio-
lence applied directly to it.
  Its middle  portion,  or  greatest convexity, is  more frequently
broken than any oiher part of  it, unless  the  fracture happens from
a direct blow; in which case  the  injury may occur where the vio-
lence is applied.   In  such  a case, the soft parts are always contus-
ed, and sometimes lacerated.   In this manner a comminuted fracture
may be produced; and,  if the violence  be  great,  the  subclavian
vessels and some of  the  nerves  converging to  form  the  axillary 
322
PARTICULAR FRACTURES.
 plexus, may be injured.   But, although  the middle of the clavicle
 is more frequently  broken than any other part of it;  yet,  in cases
 of direct violence, it usually breaks  precisely in that situation  on
 which the force has fallen: thus, if the blow has taken  place towards
 that end  of the bone which is nearest  the acromion,  then the frac-
 ture will be there;  if towards the sternal extremity of the bone, then
 that portion  of it  will be  broken.    But fractures of the  middle
 third of the bone are commonly produced in another manner.  One
 office of the clavicle is to hold the scapula at a convenient distance
 from the  sternum, so that the  motions of the  arm may have a due
 degree of freedom and extent.  Now, this disposition is one of the
 principal  causes of the great frequency of fractures of the clavicle;
 for, as this bone supports  the scapula,  every  impulse  and force
 transmitted to the shoulder is  communicated  to the clavicle,  which,
 being  slender,  first  bends and then breaks,  just as  a stick would
 break under  a force similarly  applied  to  it,  namely,  in  its  central
 part.  In consequence, then,  of the clavicle serving  as a point of
 support for the scapula, and, indeed, in particular positions,  for the
 whole of  the upper extremity, it  necessarily follows,  that,  when a
 person falls upon his arm, in an extended state, the shock will  be
 communicated along the  humerus to the glenoid cavity of the sca-
 pula, and thence to the clavicle itself; so that whether the  person
 fall  on  his hand, shoulder, or elbow, the clavicle  is likely to  be
 fractured  at its centre.
   A material  difference in fractures of the clavicle will depend  on
 one particular circumstance; namely, whether the fracture has taken
 place more towards the sternum,  than the two bands of ligament
 which tie  the coracoid and acromion processes  of the scapula to the
 clavicle.    If it has taken  place on  the scapulary side of the coraco-
 clavicular ligament, it must be clear, that there can  be very  little
 displacement, because the outer fragment will be fixed by the  liga-
 ment binding the clavicle  to the acromion, while the  inner one  is
 prevented from quitting its place by the coraco-clavicular ligament it-
 self. But when the fracture takes place within the latter ligament, or,
 in other words, more towards the sternum, yet not within the limits
 of the rhomboid ligament, which ties the  inner end of the clavicle
 to the cartilage of the first rib, there will  then  be considerable dis-
 placement, because nothing prevents the outer fragment from being
 drawn down by the weight of  the arm and shoulder, or from being
carried forwards and inwards by the  pectoralis  major and subclavius
muscles.    Hence, whenever the fracture is within the  coraco-clavi-
cular ligament, the displacement must be downwards, forwards; and
inwards.    Another fact to be  remembered is, that  it  is always the
outer fragment that is really displaced; the  inner  one being kept
from quitting  its natural  level by the action  of the sterno-cleido-
 mastoideus, and  of the  pectoralis major, which antagonise each
 other. 
FRACTURES OF THE CLAVICLE.
323
  When the fracture takes place on  the outside of the coraco-cla-
vicular  ligament, there is little or  no displacement; and, if any at
all Occur, it is only in a trifling degree, such as may be produced by
the  outer fragment being  slightly depressed, so as  to slope down-
wards more than natural.   In this  case, if we take hold of the hu-
merus, and push it directly upwards,  we find that the outer fragment
of the clavicle is brought  to its proper level again.   Some fractures
of the clavicle are  comminuted;  this may happen when  the injury
has been produced by violence;  and then the  nerves converging 10
form the axillary plexus,  are exposed to  contusion and  laceration.
The late Mr. Earle recorded an  interesting  case of comminuted
fracture of the clavicle, where these nerves had been so injured that
paralysis  of the  arm  ensued; and it  was singular  that the patient
could not afterwards put her hand into moderately warm water with-
out the  effects of a scald being produced, characterised by vesica-
tions,  redness,  &c.   The  fact  is curious,  as proving  the  share
which the innervation, or the nervous  influence, has in enabling the
different parts of the body to bear particular temperatures.
   When the clavicle is broken by  a force applied  to the  outer part
of the shoulder, the fracture is mostly oblique;  and if the violence
has been very considerable, the end of the bone may protrude through
the skin, and the case be  compound.
  The symptoms of a fractured clavicle are of the following kind:—
There is a depressed  and sunk state of the shoulder, more especially
when the fracture is within the coraco-clavicular ligament; indeed,
the shoulder will then be  considerably depressed,  and at  the same
time  inclined towards the sternum; so that the space between the
median  line  of the trunk  anteriorly  and the tip of the acromion will
be remarkably diminished.   An  attentive practitioner will at once
notice the approximation of the shoulder  to the sternum.   Then if
we  pass our  finger from the sternal extremity of the clavicle,  regu-
larly along that bone, as soon as it reaches the situation of the frac-
ture, we shall perceive a sudden depression in the line of  the bone,
arising from the  circumstance already sufficiently explained; name-
ly,  the  inclination of the  external  fragment  downwards,  inwards,
and forwards.  When we push  the shoulder upwards,  backwards,
and outwards, so as to bring the external  fragment  into its proper
situation, a crepitus is perceptible; or, even without elevating the
shoulder,  if the displacement is not so great as entirely to separate
the two ends of the  fracture from each  other;  then the crepitus
may be distinguished by putting our finger on the  injured part and
gently moving the  humerus.  When  we  first come to  a patient
whose clavicle is fractured,  we usually find him sitting in a particu-
lar  position, with bis head inclined towards  the affected  shoulder,
and his  fore-arm bent, and  quietly supported on the other hand.
He spontaneously chooses this posture, in order to  relax the sterno-
mastoid muscle, and to prevent all  motion of the upper extremity, 
324
PARTICULAR FRACTURES.
which would be  exceedingly painful to him.   Another  sign of a
fractured clavicle is the patient's inability to put  his  hand to his
forehead;  and the reason of this circumstance is, that  the humerus
has now no fixed point of support, and  is deprived of  that fulcrum
which the  clavicle  naturally  affords it.   The infirmity which  I
speak of will always  present  itself, unless ihe  fracture be  on the
outside of  the coraco-clavicular ligament; for then the patient can
sometimes  raise  his arm, and imperfectly perform  the  movement
referred to.  In other instances, he cannot bring his hand into con-
tact with his forehead, except partly by bending the fore-arm, with-
out moving the  humerus, and partly by  inclining the head down-
wards, so as to make it meet the hand.   Lastly, in consequence of
the way in which the outward fragment is displaced, there is always
a manifest  prominence, occasioned by the end of the  internal frag-
ment; the rising end of the bone, as it  was termed by the old sur-
geons, who erroneously considered it to be above its proper level.
   In  the treatment, we should always remember the direction of the
displacement, and  attend particularly to the  circumstance, that the
outer fragment is carried  inwards, forwards, and downwards,  and
that the internal one remains in its natural situation;  indeed, the out-
er one may be situated directly under it.  Therefore, in order to
replace the  external fragment, we should carry the shoulder back-
wards, outwards, and upwards, and take off the weight  of the upper
extremity.   Now in this country, in nine cases  out of ten, the con-
trivances,  used for the treatment of  broken clavicles,  are the sling
and the figure of 8 bandage,  with which the shoulders are braced
backwards.   A  roller is passed round one shoulder, and then across
the back to the  other shoulder,  round it, and  then over  the back
again, crossing the first part of the bandrge, and being continued in
the form of an 8.   But this bandage does not scientifically fulfil all
the indications required; and it even has a wrong operation;  for it
tends to draw the  shoulder  inwards, or  towards the sternum,  as
much as it inclines it backwards; and the more  tightly  it is applied,
the more it will force the shoulder inwards.   After the explanation
which I have  given of the nature  of the displacement,  1 scarcely
need remark, that this action of the  bandage is contrary to the proper
object in view, viz., that of inclining the shoulder outwards.   The
French surgeons, who seem  to have devoted great attention to the
treatment of fractures, have contrived a better method—one that is
more  judicious and efficient.  Desault, the great surgeon at the Ho-
tel Dieu before Dupuytren, employed a cushion or compress, thick
at the upper part, and thin below, or formed like a wedge.  He put
the thick end of this  wedge-like compress immediately under  the
axilla, and  fastened it there by means of two pieces of tape passed
over to the other shoulder.  Now  this compress, when the humer-
us is pressed close to the side, has the effect of  throwing  the head
of that bone outwards; so that Desault, in truth, made the humer- 
FRACTURES  OF THE CLAVICLE.
325
us a lever, with which he inclined the shoulder outwards, upwards,
and backwards, and the wedge-shaped compress was his  fulcrum,
The elbow ought to be confined and supported in a sling, and kept
close to the side with a bandage.   Various  mechanical inventions
are sold for the cure of broken  clavicles;  but,  so  far  as I can
judge, if we understand the indications to be fulfilled,  we shall al-
ways be able to accomplish every purpose with the aid of  a  com-
press, roller, and sling.
   Boyer employs first a belt, which  is  buckled  round the chest;
secondly, a piece of dimity or quilted  cloth, furnished  with four
straps, and intended to be put round  the arm.  With these straps,
the arm is fastened to so many buckles on the belt.   Thirdly, Boy-
er employs a sling to support the  fore-arm and elbow.   When  the
fracture is within the coraco-clavicular ligament,  greater  attention
will be necessary, than in other  instances,  to keep the displaced
fragment upwards, outwards, and  backwards, because the degree
of displacement is more considerable.
   If a young female of the  higher class of  society were to  break
the clavicle in  the latter situation,  she should not merely be treated
with  mechanical means, but kept  quiet in the recumbent  position
for two or three weeks, because any  deformity of the neck, caused
by irregularity in the union of the bone, which it  is often  difficult
to prevent without such precaution, would be a considerable disad-
 vantage to her.
   [Our author does not give us any definite treatment for fractures of
thu clavicle, after ;ill.  li\ this country many surgeons prefer Desault's
 bandages, but I do not regard them as meeting the indications,  and
 consider them  worse than  useless.  I have seen one patient,  who had
lost the use of his arm, from  ihe  pressure upon  the  nerves by the
wechre shaped pid, over which the  limb  is confined, in  order to  pry
 the shoulder outward.  Fat persons, and those whose lungs are feeble,
 cannot endure  the confinement of  the chest, which the  bandages im-
 pose.
   The figure of 8 bandage, confined over a cushion placed  between
 the sr.;i|>ulae, draws the shoulders back, and brings the fractured por-
 tions inio coaptation, nearly as well as it can  be done.  Mr. Cooper
 says  this form of bandage draws the shoulder inward: now such can-
 not be the case.  The principal objection to this bandage is, that  it
 presses upon the outer fractured portion, and depresses it.
   A  shoulder splint is sometimes employed, which  draws the shoul-
 der upward  and backward, and thus completely fulfils  the indications.
 The  length  of  the splint must be equal to  the breadth of the  shoul-
 ders.  One end is confined to the  sound  shoulder, by means  of a silk
 handkerchief, which passes under  the axilla, between the shoulders it
 rests upon a fulcrum or pad,  and then a  second handkerchief passed
 under the axilla of the wounded side  is tied over the other end of the
 splint and draws the shoulder upward  and  backward  and brings the
 fractured ends into place.  This splint and the figure of  8 bandag*
 are better than all  the apparatus ever  invented.—Ed.]
   vol.  n.                   28 
326
PARTICULAR FRACTURES.
                 FRACTURES  OF  THE  SCAPULA.

   The greater portion of this bone is so deep, and so protected by
 thick muscles, that fractures of it rarely take place.   The acromion
 is oftener broken than  any other part, and next the lower  angle.
 The  coracoid process is sometimes  fractured,  but much less com-
 monly than is generally believed; and, I think, the same observation
 may be made with regard  to the neck of the  scapula, which is so
 strong and so well  guarded from  the effects of external violence,
 that a fracture of it is by no means a common occurrence.   In some
 instances, portions  of the  glenoid cavity are  broken off;  but this
 also is  an event  which is  oftener talked  of than really  met  with.
 The  body of the bone is but seldom broken.   Its fractures may be
 perpendicular,  but  the greater  number of them  are transverse.
 Sometimes the scapula is fractured in more than one place; and  it
 may  be broken  in  several pieces  by great  and  direct  external
 violence.
   Fractures  of the body of the scapula  can only be produced by
 direct violence, as by a blow,  a  gunshot injury, or the passage of a
 heavy body over it.   I  know  of no  other  way, in  which  such an
 accident can happen; and  this fact explains why severe injury of
 the^soft parts generally accompanies it.   Sometimes the violence of
 the injury is  such as to  extend  its effects to the  thoracic  viscera,
 and to cause effusion of blood in the chest.
   When the acromion is   broken,  the patient  inclines his  head
 towards the injured shoulder,  the arm hangs motionless by the side
 of the trunk; an acute pain  is felt in the  situation of the injury;
 when the patient  attempts to move his arm the pain is  much aggra-
 vated, and, in consequence of the deltoid being partly attached to
 the acromium, some of  the fibres of that muscle lose their point of
 insertion, and therefore cannot afford due support to the humerus,
 which sinks  down, and  consequently a part of the natural fulness
 and rotundity of the shoulder is  lost.   In fact,  the head  of the hu-
 merus is not  held in its place  by ligaments, but  principally by the
 muscles and tendons  surrounding the joint.   A fracture of the acro-
 mion  may be known also by the presence of a crepitus; for, when
 we place one of  our  fingers  on the broken part, or hold  the  ex-
 tremity of the acromion between the finger and  thumb, and then
 push up the  humerus, or move it  freely in  various  directions, the
 crepitus will  be distinguishable.  An interspace or irregularity may
 likewise be felt between the fragments.   The shape or rotundity of
 the shoulder can be restored  by pushing up the humerus; but
 directly the arm is allowed  to descend  again, the shoulder  resumes
 the same flattened appearance, which had been noticed  previously
to the elevation of the limb.
   If a fractured  acromion  be  left to itself, it will generally unite
 either by bone or a ligamentous  fibrous substance.   Now, when 
FRACTURES  OF THE SCAPULA.
327
osseous union takes place under such neglect, the outer fragment is
liable to point more downward than it ought, and the shoulder to be
considerably weakened;  a fact, first pointed out by Cheselden.  A
fracture of the  acromion ought  to  be treated  nearly in the same
manner as a  broken clavicle.   The  first indication is to take the
weight of  the upper extremity off the shoulder, by supporting the
fore-arm in a sling, and keeping the elbow well up.   Another indi-
cation is to prevent all motion of the humerus, which is accomplish-
ed by means of a sling and roller.  A third is to incline the head of
the humerus a little outwards, an object fulfilled with the assistance
of a wedge-shaped cushion.   Some surgeons  prefer keeping the
arm raised  from the side,  in order  to relax the deltoid muscle, a   •
method which ought to be adopted  if the patient  were obliged  by
circumstances  to remain  in bed.  The acromion sometimes unites
by  bone;  sometimes by  ligament.   In  the  museum of Univerity
College are two preparations, one of which illustrates the first mode
of union;  the other, the second.
   [Fractures of the acromion process,  are not always followed by an
osseous union ; Delpecb  was in  the habit  of confining his patients to
their beds, and keeping the  arm at a right angle  with the trunk.  In
this way he  shortened the distance between ihe points of origin and
insertion of the  deltoid, and also took off  the weight of the arm, and
allowed the fractured  surfaces to come in  contact.
   In  order  to avoid the confinement, required by this plan of Mr.
Delpech, I have been in the.habit of advising the use of an  angular
splint, one side  of which was  adapted to  the  side of the body, and
rested upon the crista ilii ; the other  was adapted to the inner surface
of the arm and fore-arm, so  as to sustain them in a fixed position, at
a right angle with the trunk.   This same  angular splint,  meets the
indications when we have  a  fracture at the cervix of the  scapula to
treat.—Ed.]
   When the lower angle of the scapula is broken off, it is displaced
downwards and forwards by the action of  the serratus major amicus.
In the treatment, the humerus  may be  brought forwards across the
chest, and the hand confined upon the opposite shoulder; this position
of the limb, which has the  effect  of bringing the fragments  nearer
together, is adopted abroad;  but, in  this  country, when any  part of
the  body  of the  scapula is fractured, we  merely apply the spica
bandage, the  roller  employed for which, after crossing over the
scapula, is carried round the  joint, and  then over the back of the
trunk, to below the opposite axilla,  whence it passes in front of the
chest to the injured shoulder,  which it again  encircles.   The roller
is  conveyed in the directions here enumerated, until nearly the whole
of it is expended, when  it  is made  to conclude with  a horizontal
circle round  the thorax.    Such is  the  celebrated spica bandage,
which is of little or no use;  for it fulfils no particular indication, ex-
cept the trivial one of retaining in its place the soap  plaster, occa- 
328
PARTICULAR FRACTURES.
sionally put over  the injured part.   The sling is here the efficient
part of the apparatus.
  When the coracoid process is fractured, a great deal of mischief
is generally done  to the soft  parts of the shoulder, just  below the
clavicle;  for this  fracture can only happen from great  and direct
violence.   Hence the nature of the injury of the bone is  often  con-
cealed by the great degree of swelling.   Hence also much of the
treatment consists at first in measures for diminishing the  swelling,
as venesection, leeches, cold lotions, &c.  The coracoid process,
when broken off from the rest of the scapula,  is liable to be drawn
downwards by the short  head of the biceps, the coraco-brachialis
and  pectoralis minor, the muscles connected  with it; they ought,
therefore,  to be relaxed.   In one  complicated  instance, dissected
by Mr. South, the coracoid process was broken, about half an inch
from its tip, into two unequal pieces, the  smaller of which remained
connected above with the  triangular ligament, and below  with the
short head of the biceps, which had pulled it down as  far as the
ligament  would allow.*   In the treatment, the shoulder  should  be
kept quiet, which is effected by keeping the arm at rest with a  sling
and roller; for if  the arm be motionless,  the shoulder will also re-
main quiet.
  Fractures of the neck  of the scapula are not common accidents,
but they  are possible, and  liable to  be mistaken for dislocations of
the humerus downwards, inasmuch as the weight of the limb carries
the arm down  along with the glenoid cavity of  the scapula, and  a
hollow is  felt under the acromion.
  However, the difference between the  two  cases may readily be
perceived, by attending to the  following  circumstances.   In a dis-
location, there is  no crepitus ;  we  cannot move the humerus about
without opposition, as we can when  the neck  of the  scapula is
broken; the head of the  humerus can be felt either in the axilla, or
under the pectoral  muscles; the axis of the  humerus  is changed;
and the motions of the arm are stiff and  confined.   But, in a frac-
ture of the neck of the scapula, we cannot feel the head of the hu-
merus in either of the situations which I have specified; a crepitus
may be distinguished when we take hold of the  coracoid  process,
and the humerus is pushed up and  moved about; no particular re-
sistance  is then made to the  motion of the  arm; and the proper
shape  and position of the shoulder and  arm aie  easily restored
by pushing the humerus upwards; but, as soon as the support is re-
moved, the deformity returns.
   The treatment consists in keeping the head of the  humerus  in-
clined outwards,  by means of a thick  cushion below the axilla; in
supporting the elbow effectually with a  sling; and in preventing all
» J. F. South, in the Med. Chir. Trans, vol. xxii. p. 105. 
FRACTURES  OF THE  HUMERUS.
329
motion of the humerus by binding it to the side of the chest with a
roller.

                FRACTURES  OF  THE HUMERUS

Are distinguished into those which take place higher up than the in-
sertions of the pectoralis major and  latissimus dorsi muscles; into
those of the middle of the shaft of the bone; and into others near-
er the elbow.   Instances have  been known, in which the fracture
was situated  precisely in the true  neck of the bone:  Sir  Astley
Cooper had an opportunity of dissecting  a  subject,  in  which  he
found the fracture actually  placed,  as I have mentioned,  within the
capsular ligament.  No  bony union  had  occurred;  the  fragments
being joined together by means of  a ligamentous substance.
   A fracture through the anatomical neck of the bone, at the tuber-
cles, is  a case which has lately been further considered by the same
experienced surgeon.  He  describes the accident as being of fre-
quent occurrence in young persons; as happening more rarely in the
old; and still more rarely in the middle age.   In children, it arises
from a fall on the shoulder, and it has been known to be complicat-
ed with a fracture of  the clavicle.  As the  head of the  bone re-
mains in the glenoid  cavity, the shoulder does not lose its rotundity
as in a dislocation.   A projection of bone is  perceived upon the
point of the coracoid  process;  and  when the  elbow is  raised and
brought  forwards, this projection is rendered very conspicuous. By
drawing down the arm the  projection is removed; but it immediate-
ly reappears on the extension being  discontinued.   The motion of
the shoulder is painful; and the child can  only raise the arm with
the other hand; and the elbow is with difficulty raised from the side.
After the accident, a great quantity of ossific matter is thrown out
from the periosteum and fractured  neck of the shaft, but very little
from the broken head of the bone.   In one of Sir Astley Cooper's
preparations, a cup of bone is formed upon the fractured neck, so
as to prevent  the head from being  separated  from it.
   In a young subject, Sir  Astley Cooper  recommends treating this
case by  binding a splint on the front and back part of the arm with
a roller;  placing a pad in the axilla;  and using a clavicular bandage;
the hand, but not the elbow, being supported in a sling.   As in old
persons  the injury is more severe,  leeches, evaporating lotions, and
quietude, are  to precede the application of the mechanical means.
In the young, passive  motion is  to  be employed in a month; and,
in the old, at  the expiration of from two months to  twenty weeks*.
   When the fracture takes place somewhere between the tubercles,
and the insertions of the pectoralis major, coraco-brachialis latissimus
dorsi, teres major, and deltoid, the upper fragment has a tendency to
• Sir Astley Cooper in Guy's Hospital Reports, vol. iv. p. 277.
                   2a < 
330               PARTICULAR  FRACTURES^
 be drawn outwards by the supra-spinatus, infra-spinatus, and teres
 minor, and the lower fragment to be pulled inwards by the latissimus
 dorsi and pectoralis major, and at the same time upwards by the bi-
 ceps,  coraco-brachialis,  and long portion of the triceps.
   Fractures of the upper part of the humerus should be discrimin-
 ated from dislocations*    In a fracture, as the  head of the bone is
 yet in the glenoid cavity, there is not the hollow under the  acromi-
 on remarked  in a dislocation: however, there may be  a little de-
 pression, or diminution of the rotundity of the  shoulder, in conse-
 quence of the lower fragment being  sometimes not displaced  up-
 wards so as to produce a shortening of the limb, but, on the con-
 trary,  drawn a little downward by the weight of the part, so as to
 put the deltoid on the stretch, and thus, in one respect, a degree of
 resemblance to a dislocation may be produced.  On careful exam-
 ination, however, the head of the humerus may be  felt in the glen-
 oid cavity, and the shaft  of  the bone does  not offer that resistance
 to being moved about in various directions,  which is experienced in
 a dislocation.   In the latter case, the head of the bone may gener-
 ally be felt either in the axilla, or under the  pectoral muscles: in a
 fracture, there is a crepitus; but, in a dislocation,  this symptom is
 absent.
   In   the fracture  between the tubercles and the insertions of the
 above named muscles, when lie elbow is moved upwards, the broken
 extremity of the lower fragment projects on the inner side  of  the
 coracoid process, and it sinks when the  support of the elbow is re-
 moved.   When the arm is rotated at the elbow, the broken end of
 the main portion of the  bone is felt to roll.   There is no  marked
 depression under the acromion, or but very little  from the  deltoid
 muscle being drawn  down.   The motion of the shoulder is exceed-
 ingly painful;  and one or more of the  fingers are generally  painful,
 or contracted,  from irritation of the axillary plexus.  The diagnos-
 tic  signs are considered  by Sir Astley Cooper to be, the lodgment
 of the head of the bone in the glenoid cavity;  its being unaffected
 by  rotation of the elbow; the fractured neck being  perceptible un-
 der the pectoral muscle; and the surgeon being able to move the
 arm more freely,  than  in  other  fractures of the neck  of the
bone.*
  Mr. Robert W.  Smith has made some interesting remarks on a
fracture now and then met with, and the symptoms of which may
 completely perplex a practitioner, not aware of the  possibility of its
 occurrence.   The injury of the upper  extremity of  the humerus is
 of the following kind:—u A fracture, traversing the upper  part of
the bicipital groove,  detaches the greater tubercle of the humerus;
thus annulling the action  upon that bone of the supra-spinatus,  in-
fra-spinatus, and teres minor.   The folds of the axilla, the subsca-
* Sir Astley Cooper in Guy's Hospital Reports, vol. iv. p. 281. 
FRACTURES  OF THE  HUMERUS.
331
pularis, and the anterior portion of the deltoid, then act almost un-
opposed,  and draw the head of the bone forcibly inwards, against
the inner part of  the capsular ligament; and  if,  at  the same time,
the inner border of the glenoid cavity be broken, the head of the
bone passes still further inwards, and beneath the coracoid process,
amounting at length to an actual  displacement, which is  permitted
by the increased size of the joint, just as a displacement of the head
of the  femur will often be the consequence of a  fracture of the
acetabulum." Mr. Smith considers it not very difficult to distinguish
a fracture of the greater tubercle from a luxation of the head of the
humerus.   " One of its most remarkable and diagnostic features is
the great increase in the breadth of the articulation: moreover, the
glenoid cavity is not entirely abandoned; the acromion process is
not as  prominent as in   luxation;  the  displacement  is very  readily
produced.   We  cannot depress the  deltoid  muscle, as in disloca-
tion; and lastly,  the  violence which produced  the lesion,  has
been  directly applied  to the  injured  part."    Mr. Smith sus-
pects,  that  bony  union of such  a fracture would be  difficult to
effect.*
   Fractures of the middle  of  the humerus are very common, and
easily recognised; for when the fracture is oblique, there is a short-
ening of the limb, and  not only does  displacement  happen in  this,
the longitudinal direction,  but there is also an  angular deformity, the
limb being flexible in the situation  of the injury, in  consequence of
the solution of continuity in the bone.  A crepitus will likewise be
readily perceived, so that no difficulty can present itself in  the diag-
nosis.
   Fractures situated towards the  elbow sometimes extend into the
joint, and either the inner  or the  outer condyle may be detached.
A fracture of the external  condyle produces pain in the movements
of flexion and extension of the elbow; but Sir Astley Cooper deems
the crepitus, occasioned by the rotatory motion of the radius, the
principal  diagnostic symptom.   If the portion of the condyle bro-
ken off be  large,  it is  drawn  a little  backwards, and  the  head of
the radius with it; but if the portion be small, this displacement does
not occur.    By a careless practitioner, an oblique fracture, detach-
ing the internal condyle,  may  be mistaken for a dislocation of the
ulna backwards;  but the  error will not happen if it be recollected
that,  in such a fracture, there will be crepitus,  and that,   after we
have apparently reduced what may be supposed to be a dislocation,
the displacement  will immediately return on the limb being  left to it-
self.   But,  of all accidents about the elbow, that most likely to be
mistaken for a dislocation is a  separation of the lower epiphysis of
the humerus in a young subject, the olecranon projecting considera-
• R. W. Smith in Dublin Journ. of Med. Science, vol. xii. p. 224. 
332
PARTICULAR FRACTURES.
bly backward.   The part is readily restored to its proper shape, but,
on being left to itself, the deformity immediately returns.
   In the treatment of fractures of the humerus, the principal indi-
cations, after the requisite extension,   counter-extension, and coap-
tation, have been performed, are, first, to support the fragments du-
ly in their proper position  with respect to each other; secondly, to
prevent all motion, not only of the broken bone  itself,  but also of
the ulna and the radius.
   When the fracture is situated above the insertion of the pectora-
lis major and latissimus dorsi, Sir Astley Cooper recommends splints,
the clavicular bandage, arid the wedge-shaped pad in the axilla, with its
broader part upwards; but, says he, " above all,  it  is necessary to
permit the arm to hang by the side unsupported at the elbow, so as
to let the weight of the arm be a constant source of extension upon
the broken  end of the bone."  In one  case, Mr. Tyrrell  failed in
keeping the fracture in a state of coaptation,  until he had recourse
to a  rectangular  splint,  a  part of which rested  against the side,
while the arm,  raised to a right angle, reposed  upon the other part
of it.
   When the fracture is situated in the middle third of  the humerus,
it is usual to apply either two or four splints; some practitioners  use
four,  and others only two;  one on the outer  part of the arm,  and
the other on the inner side of it.   A sling is always necessary.   An
assistant is to take hold of the elbow and  hand, and support the fore-
arm, while the  surgeon puts on the apparatus;  during which part of
the business, the former should make a little extension, so as to
bring the ends  of  the fracture in apposition.
   When the fracture takes place more towards the elbow joint, com-
mon  splints  are  deficient in one  material respect; namely, they
cannot control  the movements of the radius upon  the articular sur-
face of the humerus.   Such splints can operate  also but  trivially
and imperfectly,  even in steadying the fragments  of a fracture  so
low  down;  for  only a small part of the apparatus extends below
the solution  of continuity.   Of late years, therefore, it has been
customary in cases of this description to employ an angular splint,
one part of which is adapted to the inner side of  the arm,  and  the
other part to the palmar side of the fore-arm.   I  consider  this ap-
paratus far more efficient, and better calculated to fulfil  scientifical-
ly the chief indications.   The angular splint, put on in  the manner
I have explained, acts powerfully in keeping  the humerus steady,
and in preventing all motion of the  elbow-joint  and  bones of the
fore-arm.   Simple as the contrivance is, and essential  as  it is to
the successful  treatment  of  fractures  near the  elbow, it has  only
been  employed a few years.  Of course,  the arm is  to  be  put  in a
sling  in this, as well as in other fractures of the humerus.
   When the outer condyle is detached, we should  relax the mus-
cles arising from it, which is accomplished by placing the  hand in 
FRACTURES  OF THE  FORE-ARM.
333
the supine position,  with  the fingers extended; on the contrary,
when the inner condyle is broken  off, the  muscles, arising  from
that process, should be relaxed,  which is done by placing the hand
in the state  of pronation, with the  fingers  bent.  If the  hand  be
kept supine, the angular splint, already described, will  not fit the
limb; and another kind of splint, which is also an angular one, but
so contrived as to accommodate  itself to the  front of the arm, will
be  useful, with  a corresponding  one for the  posterior part of the
limb.
   If, when a  surgeon is called  to a fracture of the humerus near
the elbow, he should not happen  to be provided with angular splints,
1 recommend him to use strong thick pasteboard, which, after be-
ing softened in water, is to be applied.  When dry,  it will form an
excellent case for the limb, answering  in every respect as well as
the angular splint.
   In the treatment of fractures of the  lower end of the humerus,
passive motion should begin at the  expiration of three weeks  in a
child, and of  four in an adult, in order to prevent anchylosis.
   Sometimes the humerus is  first dislocated into the  axilla, and  its
head then broken off, which  is thrown on the inner side of the  in-
ferior costa  of the scapula.   Sir Astley Cooper has seen  many of
these cases  in the living, and  has dissected  three in the dead.   In
one of the latter,  the fractured neck of the  shaft of the humerus
was situated in the glenoid cavity, widely separated  from  the head
of  the bone; and the end of the  broken bone had formed  with the
glenoid cavity a new and good articulation, with  a capsular ligament
over it, partly of new production.
   With regard to  the diagnosis, the depression   of the shoulder  is
less striking than in simple  dislocation  into the  axilla; the head of
the bone can be distinctly  felt in the latter situation, but does not
roll when the  rest of the humerus is rotated; a  crepitus may gen-
erally be felt,  if the elbow be raised outwards,  and  the arm rotat-
ed; the end of the shaft advances  towards  the coracoid  process,
and though  readily moved back,  it easily slips forward again; and,
lastly, the violence required for the  production of this accident be-
ing greater  than  that causing a  simple  dislocation,  the degree of
contusion and the  pain and swelling are more considerable.  Here
extension is only useful in  bringing the upper end of the shaft  into
the glenoid  cavity,  where a useful joint is  formed.  The  head of
the bone is  not acted upon by it.   A pad is to be placed in the ax-
illa, a clavicular bandage used, and  the  arm supported in a sling.*

                FRACTURES  OF THE  FORE-ARM

Are remarkably frequent.   Fractures of the  radius perhaps happen
• Sir Astley Cooper in Guy's Hospital Reports, vol. iv. p. 272. 
334
PARTICULAR  FRACTURES.
 as often as  those of any other bone in the body, except the clavi-
 cle; and  the reason of this  is, because  it  is articulated  with the
 carpus, and has to receive all the force communicated  to the  hand
 in falling, and indeed  on every other occasion.   When  a person
 falls, he stretches out his hand to save himself;  this part then comes
 violently  in contact with the ground, and the force is  immediately
 communicated from it to the radius, which  bends and gives way
 generally  in its  central portion, but sometimes near the  wrist, a
 fracture of the upper end of the radius rarely or never happening in
this manner.  The majority of fractures of the  radius take  place in
 its middle third, or near the  wrist; and  when the upper part  hap-
 pens to be  broken, the injury is produced by a blow,  or some
 species of  direct violence.   Another  reason why the radius is
 oftener fractured than the ulna is,  that the former is situated at the
 outer and upper part of  the fore-arm, so  that it is more exposed to
 the action of direct violence than the neighboring bone.
  [A fracture at the cervix of the radius, is said never to  occur;
such is not  the fact.   Professor Watts, of the College of Physicians
 and Surgeons, of this city, has in  his museum  a  beautiful  specimen,
showing a fracture at  this point in the radius.   It  is united  by  liga-
 ment.—Ed.]
  When  a  fracture of  the  radius  is suspected, we should first in-
quire, whether the patient can or cannot perform the movements of
pronation  and supination of  the hand; for if  he  can do these well,
then we may be certain that the radius is not broken.   Or  we may
take hold  of the patient's hand and rotate the radius for him, while
the fingers of our left  hand  are  placed upon it.  If  the  bone is
not broken, the  upper portion of  it will follow  the   movements
of the  hand,  as  it  always  naturally  does; but if it is  broken,
considerable pain will be  felt  on  attempting  these  motions  of
supination and pronation—there will be a crepitus; and the upper frag-
ment wjll remain  motionless.  In many instances there is displacement,
the  lower  portion  of the bone being in  the prone position, and
the  upper  in the supine one; and the ends of fracture tending towards
the  inter-osseous space.   There can be no alteration in the length
of the  bone or limb, while the ulna remains  perfect, and serves as
a kind of  splint.
  When both  bones  are broken,  the nature  of the  accident is still
more obvious, because  there  is an angular deformity of the limb,
and  a  distinct crepitus, as well as a loss of the motions of supina-
tion  and  pronation.
  Fractures of the ulna alone are  generally  produced by direct
violence,  as blows, kicks, &c; for any  force or violence  commu-
nicated to the hand has little or  no effect upon that bone.   This
circumstance enables us at once  to understand why, when  the ulna
alone is broken,  it is generally by direct violence;  and why,  also,
when both bones are  simultaneously  broken, it is most commonly 
       FRACTURES  OF THE  BONES OF  THE FORE-ARM.    335

also by direct violence, such as the passage of a heavy body over
the arm, or a violent fall, or blow on the  injured part.
  When the  radious is broken, we should bend the elbow, and then
make a  little  extension and  counter-extension, taking care to avoid
pressing the ends of the fracture into the inner-osseous space.   It
is a grand point in the treatment to preserve the inter-osseous space
perfect; for,  if we neglect this indication, the radius and ulna may
grow  together, and the motions of supination and pronation be for
ever  lost.    Splints for the  fore-arm, therefore,  should  not  be
jointed longitudinally, but be  rather of  a  flat or trivially excavated
shape; and in particular, a tight bandage, which would depress the ra-
dius too much against the ulna, ought not on any account to be em-
ployed.    Two splints are commonly put  on; and,  after the reduc-
tion, either no roller at all should be applied directly to the fore-arm
itself, or merely a  slack  one.  Then one of the splints,  properly
padded  or lined with soft materials, is to be laid  along  the inner
part of the fore-arm, from the bend of the elbow nearly to the ends
of the fingers, and another along the outside of this part of the limb.
It is generally considered best to keep the radius nearly in the mid-
state between pronation and  supination.  Sometimes when the ra-
dius is broken near the  wrist, and a good deal of swelling is pre-
sent,  we might be inclined  to suppose  the  case  a  dislocation; but
generally there will be no difficulty in making out that the case is a
fracture, for  (to say nothing of the rarily of such a dislocation) the
nature of  the injury  is generally indicated by a crepitus, except  in
young subjects, in whom the case  is often a mere separation of the
epiphysis.  We can also constantly feel the styloid process below
the solution of continuity.   In this case,  if  displacement occur, the
lower fragment is mostly drawn backward by the action of the long
supinator and extenso carpi  radialis,  but, in  few  instances, forward
by  the influence of the pronator quadratus.  The  reason of the
greater frequency of the displacement backward is in some measure
explained by  the patient  usually falling  directly on the hand  at the
period of the  accident, by which means  the fragment is forced  back-
wards.   The fragments must be put into the proper position, and
splints and a  sling employed,  due  care  being taken to prevent the
hand from inclining too  much downwards.
   The olecranon is most liable to  be fractured by falls on  the elbow
and not  usually by the action of muscles, as is  the case with the
knee-pan.  It may be broken  at its point, or more towards its base.
In some instances, when  the  fracture occurs near its base, and the
ligamentous fibres, extending  from the olecranon to the  coranoid
process  of the ulna, are not  completely  ruptured, the upper frag-
ment  may not be displaced or retracted; but if those fibres be com-
pletely torn,  the  upper fragment will be drawn up wards by the tri-
ceps.   The extent of separation between  the fragments will also be
influenced by the circumstance, whether the elbow  be  bent or ex- 
336
PARTICULAR FRACTURES.
tended; for, in the latter position, the lower fragment does not con-
tribute to  the  displacement at all;  but, when the arm  is bent, the
lower fragment recedes, and materially increases the interspace be-
tween the fracture.   When the upper fragment  is drawn away from
the lower one, no crepitus  can be perceived, unless the arm be ex-
tended, and the upper fragment pressed down;  but the  nature of the
case will  always be clear enough, even without this symptom, ex-
cept when the limb is much swelled.   Indeed,  the swelling, conse-
quent  to  fractures about the elbow, is frequently  prodigious, and
comes on with surprising  rapidity;  so  that it is an object always to
examine the limb well at an early period,  before any obscurity  has
arisen  from the enlargement of soft parts.   Whether the patient re-
tains much power of extending  the arm, materially  depends upon
whether the liga mentous fibres,  spread over the olecranon from the
coranoid process, happen to be  torn or not; because if they should
be completely ruptured, that power would be exceedingly diminish-
ed.
   There is a  difference of opinion  among practitioners, respecting
the best mode of treating fractures  of  the  olecranon.  We should
naturally suppose that the limb ought  to be  kept  extended, the
greatest approximation of the  fragments being  thus produced; but
Desault, the great predecessor  of Dupuytren,  at  the  Hotel Dieu
in Paris, objected  to this posture of the  limb,  on  the  ground that,
although the fragments grew together,  yet they were  separated at
their  internal  edges, and  the joint remained  permanently  weak.
Hence he recommended a middle  position, between the  half-bent
and  perfectly  extended state, or,  in  other words,  a  trivially bent
position of the elbow.   The same practice is  also preferred by a
few surgeons of the  present day, as being, according to their judg-
ment,  less irksome to the patient and  more  efficient,  inasmuch as
the cure takes place without any imperfection being  left  in  the ac-
tion of the joint.   But I do not consider  this point  as one entirely
settled; for several practitioners of the greatest experience, among
whom is Sir iYstley  Cooper, are decidedly of opinion, that the ex-
tension should  be complete.  Sir  Astley Cooper finds, as other
surgeons do, that the  olecranon generally unites by ligament; and
he observes, that if the limb be  kept somewhat bent, there will be
greater length of the ligamentous substance, and the joint will he a
proportionably weaker.  The late  Mr.  Sheldon was  an advocate
for complete extension; and, as far as my own experience goes, I
have found no reason  to  follow Desault's  advice  on  this  matter.
In fact, I have never seen any ill  consequences from keeping the arm
extended,  and mean to follow this method, until  its disadvantages
have been more clearly proved.  Frequently, in a case of fracture
of the olecranon, we cannot apply the bandage, or any splint, until
the fourth  or  sixth day after the accident,  and sometimes  not till
later.   Now this is  one example, in which the good  general  rule 
       FRACTURES  OF THE  BOXES OF  THE  FORE-ARM.    337

of applying the splints, as soon as possible, to a broken limb, should
be dispensed with; our duty is to try to  reduce  the inflammation
and swelling before any apparatus, that makes pressure on the limb,
can be advantageously applied.   We are  called upon,  therefore, to
employ leeches,  cold evaporating  lotions,  purgatives, and  even
bleeding from the other arm,  if the inflammation and  swelling are
very considerable.   The  inflammation  having  been reduced, we
put on a figure of 8 bandage, which will answer pretty well,  espe-
cially when a well-padded splint is laid along the front of the  limb,
in order to prevent flexion  of the joint.   If we choose  to  adopt
the plan of slight  flexion, we may put on  a splint  constructed with
a kind of hinge, or joint,  exactly in front of the elbow, and fur-
nished with  a screw  by means of which its degree of flexion can
be regulated and fixed.
  In compound fractures of the olecranon, in  consequence of the
degree of  inflammation and swelling sure to ensue, it is best not to
apply any splint or bandage at first;  but to lay the limb on a pillow,
close the wound, and try  to keep down inflammation  of  the  joint
with cold  evaporating lotions,  leeches, venesection, and saline pur-
gative medicines.   If  matter form, an early opening is to  be made.
Bad comminuted  fractures  of  the  olecranon sometimes occasion  a
necessity for amputation, as was exemplified in  the case of Charles
Hussey, under my care in  University College Hospital, in Novem-
ber, 1835.
  When the coronoid process  is  broken, and the arm extended, the
olecranon  projects back in such a degree  as to create  the appear-
ance of a  dislocation; but it may be known that this is not  the case,
because,   directly  the arm is  bent,  the  olecranon  returns  to  its
natural place again; and in  addition to this circumstance, a crepitus
can be felt.   The treatment consists in keeping  the  fore-arm and
elbow at rest in the bent position, and applying a  figure of 8  band-
age round the joint, after having had recourse  to leeches, cold lo-
tions, &c. for three or four days, in the event of the swelling being
considerable.
  But fractures about  the  elbow  are not always  so simple as the
cases we have been noticing; they are sometimes very complicated.
Thus one preparation in the museum of University  College  illus-
trates a case, in which the ulna is broken at the elbow, the posterior
fragment being displaced backwards by the action of the triceps;
the coronoid  process is broken off;  the upper bead of the radius ia
also dislocated, from  the  lesser sigmoid cavity of the ulna, and
drawn upwards by the  action of  the biceps.  In this  complicated
accident, the ulna is broken in two places.
VOL.  n.
29 
338
PARTICULAR FRACTURES.
FRACTURES OF THE CARPUS, METACARPUS, AND  BONES OF THE
                           FINGERS.

   The carpal and metacarpal bones  can be broken only by great
direct violence, as  by gun-shot  wounds, the  action of  machinery
on the parts, or the passage of the wheel of a heavy carriage over
them.  Now, under these circumstances, so much injury is frequent-
ly done to  the soft parts, that it becomes  necessary  to amputate
without delay.   However, if the case will  admit of an attempt be-
ing made to preserve  the limb, or  any part of the  hand, the main
indications will be, to remove all loose splinters of bone which are
near the surface, to apply for the first three or four days light su-
perficial dressings and cold lotions, and afterwards emollient fomen-
tations and poultices,  till the inflammation has subsided and the
sloughs have been detached.   If there has not been much bleeding
from the  part, leeches may be applied to it.   The bones of the fin-
gers are seldom fractured,  for they can  only be broken by direct
violence.   The treatment is simple, the injured  finger  merely re-
quiring to be supported  with  pasteboard, and the  hand kept in a
sling.

                 FRACTURES OF  THE  PELVIS.

   The particular  shape  of the  pelvis, the sort of circle or arch
which it represents, and  the vast strength and thickness  of its seve-
ral bones, are  circumstances at  once apprising us, that  the pelvis
can be broken only by great and  extraordinary degrees of violence
directly applied to it; as by the passage of a heavy waggon over it, or
by its being pressed between the wheel of a carriage and a wall or
post.   From the manner in which these  fractures  usually happen,
it is manifest,  that the injury done to the bones is unfortunately not
the most serious part of  the  mischief; the soft parts generally, and
often the bladder or  colon,  being seriously  injured.    Sometimes
the bladder or intestines  are ruptured; sometimes blood  is extrava-
sated either in the abdomen  or  the pelvis;  and, in other instances,
where the rami of the ischium and  ossa pubis  are  broken, spicule
of the bone may be driven into  the bladder or urethra.   A prepa-
ration  in  the museum of University  College  illustrates  a case,  in
which  there was a fracture of the ramus of the  ischium, and  one
of the  fragments tore  the urethra;  the consequence  was  an effusion
of urine in  the cellular substance of the perineum, and sloughing  of
all the parts among which the urine passed.   Another  preparation,
in the same collection, was taken from a person, whose rectum was
lacerated  by a  portion of fractured  sacrum.  In such  cases, one
frequent consequence is  a paralysis of the bladder  and  lower ex-
tremities.   In gun-shot fractures of the pelvis, spiculse of bone may 
FRACTURES OF THE THIGH-BONE.
339
be forced completely into the bladder, and afterwards become the
nuclei of calculous formations, so as to oblige the patient to submit
to the operation of lithotomy.
   Fractures  of the anterior superior  spinous process, and of the
crista of  the ilium, may take  place, without  much additional mis-
chief;  but other fractures of the pelvis are frequently fatal.  I have
seen two cases, in which the  accident arose from the passage of
heavy waggons  over the pelvis:  one  of these  patients  died  in  a
quarter of an hour.   There will  sometimes be  effusion of blood in
the abdomen; and, in other instances, the bladder or intestines are
ruptured.  The fracture sometimes extends through the acetabulum,
and then the case  is  liable  to be mistaken for a dislocation of the
hip; because the superior fragment is drawn upwards, and the limb
consequently shortened, while the trochanter major is thrown a little
forward:  and thus there will be two symptoms  of a dislocation  of
the hip.   However,  if the  hand  be applied  to  the  crysta of the
ilium, and the thigh bone  be then rotated, there will be no difficulty
in making out the accident;  for  there will be a crepitus, and not
that considerable resistance  to motion  of the femur,  so  invariably
experienced in a dislocation.
   With regard to  the treatment of fractures of the pelvis, if we ex-
cept antiphlogistic measures, there is not a great  deal to be done.
A bandage might be applied round the  pelvis; but, as its usefulness
is questionable, the best practical surgeons do not have recourse to
it.  We should bleed the patient freely, to prevent inflammation of
the pelvic viscera; and if the bladder  or urethra  were ruptured  or
paralytic, a catheter should be passed, to  prevent effusion of urine.
In the latter case, we should keep the  catheter  in the  passage, lest
the urine escape by the lacerated opening into the cellular membrane,
whereby  great, and sometimes fatal, mischief would  be produced.
Repose,  antiphlogistic  measures,  and  attention  to any particular
symptoms,  which  may arise, but especially retention of  urine,
are the chief objects in the  management of fractures of the pelvis.
   Some fractures  of the  pelvis  have a favorable  termination, the
bones uniting, and the patient recovering.  One preparation, in the
museum  of University College, was taken from a person, in whom
the sacrum and os innominatum had both been  fractured; yet, the
broken parts united, so that the patient probably lived long after the
injury.   The chances of  recovery depend, however, on the degree
of violence with which  the injury is inflicted, and  its effects on the
viscera;  and, if the bladder, bowels, medulla spinalis, and  other
important organs escape injury, the patient may  ultimately get well.
Sometimes he dies of peritonitis, of which I have seen instances.

               FRACTURES OF  THE THIGH  BONE

Are divided into three classes, in respect to situation: the first com- 
340
PARTICULAR FRACTURES.
prises those in the upper part, or in the neck, of the bone; the se-
cond, such as take  place in the middle third of its shaft;  r.udile
third, fractures situated  in the lower third of the shaft,  or towards
the condyles.   Those in the middle of the shaft are most frequent
in persons under a certain age; but in  old subjects, fractures of the
neck of the bone take place with remarkable frequency.
   Fractures of the shaft of the femur  may be simple or compound;
they may  also  be complicated with a wound of the femoral artery,
which, however, is a rare occurrence.   Sir  Astley Cooper met
with such  a case, in which  it was necessary to perform amputation.
Fractures of the thigh bone may also be double.   In children, the
shaft is frequently broken in the  transverse  direction; but, in other
subjects, the fissure is most commonly oblique.  The fracture may
be caused by direct violence, as  by the  passage of the wheel of a
heavy carriage over the limb, the fall of a heavy  body upon it, the
kick of a  horse, and  various other  kinds of injury;  but,  on  other
occasions, the femur is broken by some description of force, which
first bends it, and when  it has yielded  as much as  it can, it breaks,
generally at some point  of  its middle third.
   What  are the symptoms of  a fracture  of  a shaft  of the thigh
bone?—Supposing  the  fracture to  be oblique, a shortening of the
limb is usually noticed,  the lower fragment being drawn behind the
upper one, and a little inwards; the  limb is flexible in the situation
of the fracture; the lower  fragment, with the  knee, leg, and  foot,
is rotated  outwards, all the stronger  muscles, acting upon that part
of the broken bone, tending to twist it in this direction.   Although
the lower  fragment  is commonly drawn upwards and inwards behind
the upper one, it  is possible for the  lower fragment to  be displaced
in a different manner, and  so as to lie in front  of the  upper  one;
but this  occurrence is a deviation from what is ordinarily seen, and
is explicable by the particular mode in which the accident has been
produced, viz. by the application of direct  violence, and the oper-
ation of the force upon  the  posterior part of the limb, so as to pro-
pel the lower  fragment  forwards.   Another symptom of a broken
thigh is a  crepitus,  that can  be  distinctly  felt  on  moving the limb.
If the fracture be an oblique one, together  with the shortening of
the limb,  there is a rotation of it outwards, and, what is termed the
angular deformity, the axis of one  portion of the  bone not corres-
ponding to that of the rest  of it.  The retraction of the lower frag-
ment constantly occasions an increased bulk, or fulness of the up-
per part of the thigh, because  the  attachments of several of the
muscles are brought nearer  together, and their bellies swelled into a
preternatural shape.  The truth of this observation is well illustrat-
ed  in the state of the adductor muscle, which, by forming a con-
siderable prominence at the upper and inner part of the thigh, com-
municates to it a  very  unnatural shape.   That it  is  the muscles
which produce the  displacement of the fractures, cannot  be doubt- 
              FRACTURES  OF  THE  THIGH-BONE.            340

ed, because, if the muscles of the broken limb were paralytic, there
would not be any retraction of the lower fragment, or shortening of
the thigh.   In a person affected  with paralysis, there might be no
shortening of the limb at first, or  while the muscles were incapable
of action; but if the paralytic affection happened to yield before the
fracture had united, a retraction of the  lower fragment would yet
ensue.   Indeed, such a  case is recorded  by Bichat.   When the
accident took place, all the muscles of the lower extremity were in
a paralytic state; and though  the  fracture was an oblique one, no
retraction whatever of the inferior fragment followed.  The  moxa
was applied, and,  in a few days, the muscles  began to regain their
power of action; and in proportion as this improvement was effect-
ed, the ends of  the fracture  acquired a tendency to  displacement,
not previously evinced, and  a considerable retraction of the  lower
fragment ensued.  In transverse fractures  of the shaft of the femur,
no  shortening of the  limb  may  happen, yet the  angular  deformity
and rotation outwards will  be observed.   The  foregoing  observa-
tions render it manifest,  that it is chiefly the  lower portion of the
broken femur which is displaced; but it would  be incorrect to re-
gard the displacement as exclusively affecting only the lower frag-
ment.   When the  patient is placed on too soft a bed, which yields
to the weight of his trunk, the  pelvis sinks, and pushes  the upper
fragment along with it, which thus has a disposition to be  propelled
over the lower one.  Supposing also the fracture to be situated just
below the trochanter minor, the psoas and  iliac  muscles,  attached
to that process,  might act with great effect in displacing the  upper
fragment in  the direction forwards and upwards.
   It  was principally  with reference to fractures of the lower  ex-
tremity,  that Pott recommended the plan of attending to the relax-
ation  of the muscles as the best means of facilitating  the reduction,
and promoting the maintenance of the fragments in their right place.
One would  suppose, from several passages in his treatise, that be
really imagined  it   possible completely to relax all the muscles by a
certain position  of  the limb, and this  in such a manner as entirely to
deprive them of all power of disturbing the ends of the broken bone.
No position of the limb, however, will  do so much as this eminent
surgeon was induced to believe.    A certain position may relax those
muscles, which have the greatest power of disturbing the fracture;
yet the mass of muscular fibres remaining unrelaxed,  will always be
sufficient to  derange the fracture; and consequently position alone,
however important and useful it may  be, will not accomplish strictly
what  Mr. Pott represents; it will  not effectually deprive the muscles
of  the power of disturbing the fracture.   This  truth enables us at
once  to understand how necessary it  is to attend  to other means for
maintaining the  reduction, and especially  to avail ourselves of the
best mechanical contrivances  for this purpose.   So correct is the
principle which  I am now adverting to,  that if the particular posi-
                            29* 
342
PARTICULAR FRACTURES.
tion of the limb, selected for the  purpose of relaxing the muscles,
were to be incompatible with the employment of the most efficient
apparatus,  then, the treatment would be erroneous, because, advan-
tageous as position may be in relaxing the most powerful muscles
connected  with the broken limb, the aid  of  an efficient apparatus is
still more important.   From what is stated in my general observa-
tions on Fractures, in the first section of this work, even the supe-
rior usefulness of relaxing the muscles is now sometimes disputed,
and the plan of keeping  them in the  opposite  condition  advoca-
ted.
  Broken thighs are treated on three different plans, each of which
is  occasionally preferred.   In the first, the  limb  is kept extended,
and the patient lies on his back; a position disapproved of by Pott,
because it  does not  relax those muscles  which have the greatest
power in producing displacement, namely, those which are capable
of drawing the lower fragment upwards, inwards,  and behind the
upper one, or,  in  other terms, the muscles arising  from the pelvis,
and inserted either into the femur, the patella, the tibia, or the fibu-
la, and which, making the pelvis their fixed point, and the portion of
the limb below the fracture  their moveable one,  displace the lower
fragment in the foregoing direction.
  In  the  extended  position,  various kinds of long  splints are em-
ployed.  Desault  employed three splints; one on the outside of the
limb, a second on the inside, and a third  on the upper part, or front
of the thigh.   He was very particular  in placing the patient on a
firm unyielding bed;  for if the pelvis sinks into a hollow of the bed-
ding, this change  will  inevitably derange the position of the frag-
ments.   He began with applying the eighteen, or many-tailed band-
age, then a long splint, well padded, on the outer part of the limb;
he next put a handkerchief or band on the perineum, or rather on the
tuberosity of the ischium, the ends of which handkerchief or band
were carried through a fissure in the upper part of the long exter-
nal splint,  and  the effect of this was to prevent the splint from slip-
ping upwards.   Then  the foot was  also made steady by passing a
handkerchief or bandage  through a fissure in the lower  part of the
splint, which was  brought over the foot  across the  instep, and then
fastened to the splint again.   Thus the limb was fixed and  secured
both at the hip and the foot.   Other splints, however,  were made
use of: one at  the inner side  of the limb, extending  from the groin
to the foot; and a shorter one, reaching  along the front of the thigh
from the groin  to the kneepan.
   Boyer invented another apparatus, which was also intended to be
used in the straight position of the limb.   His long  external splint
is furnished with a screw at the lowrer end, by means of which it can
be lengthened  or shortened  at pleasure.   The principle of his ap-
paratus is to keep up permanent extension; but, for the screw to have
its  full effect, it  is necessary that the upper  end of the splint 
FRACTURES  OF THE THIGH-BONE.
343
should be securely fastened to the pelvis.   For this latter purpose,
Boyer put a thigh-strap over the tuberosity of the ischium, much
in the same manner as Desault did  the handkerchief, or band ;  but
the  portion of the thigh-strap below the crista of the  ilium, on  the
outside of the pelvis, had a kind of fob or pocket in it, calculated to
receive the upper end of the splint, and thus prevent it from slipping
upwards, or moving at all laterally.   The limb having been first put
up with the many-tailed bandage, the long external splint, lined with
soft materials, is applied; the foot is next fixed much in the same way
as in  Dcsault's  plan, and the inner and upper splints are put on, the
extension being kept up by lengthening the outer splint, which is done
by turning the screw at the lower part of the splint.   In University
College Hospital, we adopt the straight  position, and employ only
the external long splint, which  with a  handkerchief, rolled  up and
filled  with soft materials, and common rollers, compose the whole of
the apparatus.   If we ask ourselves, what are the indications to be
fulfilled?  the answer is, to keep the broken part of the bone steady;
to maintain the limb to its proper length; and to hinder it from turning
too much either outwards or inwards. Now, for these purposes, some-
thing  is  needed  as a fulcrum,  to which  the  limb is  to be bound.
The splint is converted  into this  fulcrum by  its upper end  being
fixed  to the side of the pelvis with  the handkerchief, that  passes
under the tuberosity of the ischium, and the ends of which are then
conveyed up to the  fissure in  the upper  part of of the splint, and
there fastened to it, so as  to keep it from  slipping upwards.   When,
therefore, the limb  has been bandaged, the long splint placed along
the outer side of the limb, and  the foot and rest of the limb have
been  secured in the best position to  this splint  with  rollers nearly
 as far up as the fracture, the next thing  is to  make as much further
 extension  as may be needed, and then  fasten the two ends of  the
handkerchief  to the notch in  the upper  end  of the splint, so as to
 prevent  it, and of course the  limb,  which  is bound to  it, from
becoming retracted.   These  are the simple and admirable princi-
 ples,  on which alone fractures  of the  thigh can be  very  success-
 fully  treated.
   The second plan of treating  fractures of the  shaft of the femur
 is that recommended by Pott,  in which the limb and the pelvis  are
 laid on their external side, with the thigh half bent upon the  pelvis,
 and the leg moderately bent upon the thigh.   In this method, two
splints are sometimes applied,  but generally four.  The fracture is
reduced by an assistant taking hold of the limb  above the broken
part of the bone, and performing  counter-extension,  while the sur-
geon  makes extension from a part of the limb below the situatiui of
the injury. The patient is laid  on his side, with the pelvis inclining
as much as possible in the same direction. The limb is placed on its
outer side, with the  thigh half bent upon  the pelvis, and the leg bent 
344
PARTICULAR FRACTURES.
in a similar degree upon the thigh itself.   Before reducing the frac-
ture, the long splint, with the pad and eighteen-tailed bandage upon
it, should be put under  the thigh; the reduction of the  fracture is
then to be accomplished, and the tails of the bandage next methodi-
cally laid down, one over the other, beginning with those just above
the knee.  The eighteen-tailed bandage, when neatly applied, looks
exceeding wrell,  and is convenient; for it can be opened without
the slightest disturbance of the  fracture, or motion of the limb.  In
private practice, it is usual to apply, under the bandage, a piece of
brown soap plaster to the integuments in the immediate  vicinity of
the fracture.  By proceeding in the manner here explained, the other
splints may  be applied with the greatest  facility.  When Pott's
position is adopted, one important thing is to afford due support to
the foot, for  which purpose a soft cushion or pillow is generally em-
ployed;  and  the knee must also be  supported by a similar means.
But this  treatment of broken  thighs  in  the bent  posture, with the
patient on his side,  is not  exactly  consistent with the most scienti-
fic principles.  In the first place,  one general principle, acknow-
ledged by all the best practical surgeons, is that of keeping all joints
in any way connected  with a  fractured bone, perfectly motionless;
but here no measures are taken for the fulfilment of this very impor-
tant object.  On the  contrary, the patient  can  move  every joint
without restraint.   The splints do not confine either  the hip, the
knee, or the  ankle; hence, I should  say, that this  is  an inferior
method of treatment, and I am not surprised  that  it should be  one
which occasions deformity more frequently  than  any other, and is
losing ground from day  to  day in the estimation of the  profession.
But supposing  this  position  were  in  some respects the best  that
could be  selected, yet,  as it could not be maintained for  any length
of time, it would prove inefficient.   In  fact, take  what pains we
may, the  patient will never remain long in the posture specified, but
will always turn on his back, and thus the fracture will  become de-
ranged again.
   A third plan has been proposed and  adopted,  which consists in
placing the patient on his back,  with the thigh bent on the pelvis,
and the leg bent on  the thigh,  while the limb is supported in  this
position on the double inclined plane.  The most simple instrument
of this kind merely consists of two boards  of the  requisite length,
nailed together at an angle, and provided with a foot-piece, and a
few pegs  along the margins, to keep the pads from slipping off the
apparatus.  Double inclined planes,  however, are  now brought to
great perfection;  and fracture-beds, as they are called, are general-
ly so constructed as to  admit of serving the same purpose.   Ames-
bury's apparatus, which answers as a double inclined plane, is a very
good one; but, in University  College Hospital,  whenever 1 have
adopted  this  position for  a broken thigh, the  preference has been 
       FRACTURES  OF THE  NECK OF  THE THIGH-BONE.   345

given to M'Intyre's  apparatus, which  is more simple, and does not
require, in addition to the front  splint, any lateral ones, unless the
thigh be   very  bulky;  or  even the eighteen-tailed bandage; a com-
mon roller being applied so as to  include both the limb and the ap-
paratus on which it lies,  and,  consequently, admitting of removal
without any disturbance of the part.   All well made double inclined
planes can be fixed at  any angle by means  of a screw.   In Ames-
bury's apparatus, the thigh part may be lengthened or shortened at
the surgeon's option, which is an advantage, the brass part sliding very
conveniently in either direction.    The foot-piece also  admits  of
being shifted, and its position and length can  be adapted to the partic-
ularities of every case.  If this, or any other double inclined plane, be
used, we have no occasion for an under splint, because  the surface of
the machine itself answers the purpose of one. The ankle is kept stea-
dy by means of the leather case or slipper for the foot, M'Intyre's ap-
paratus may be used without any other splint, though when the thigh is
very bulky, an anterior splint is useful.  The limb, after having been
covered with a roller,  is laid  upon  the apparatus, coaptation  per-
formed, and then the  limb and apparatus  together encircled with
other rollers from the foot up to the pelvis.    Thus the limb will be
kept perfectly steady, and  all the joints motionless.   By means  of
the thigh-strap and pelvis  strap belonging  to the apparatus, the pel-
vis and lower extremity are also rendered, as it were, one piece,
only moveable together.   The strap is passed round the  pelvis, and
through the fissure in the upper part of the external splint, near the
great trochanter.   Amesbury's inclined plane is excellently finished,
and the splints of a good shape, light, yet strong.   With  this appar-
atus, three splints are intended  to  be used  for a  broken   thigh, and
also  the eighteen-tailed bandage.   In some  hospitals, the treatment
of broken  thighs on a double  inclined plane is preferred to the meth-
od of Desault,  with all the improvement and simplicity to which  it
has now been brought.  A double inclined  plane is always  to be
well covered with soft materials, especially the projecting part of it
under the  ham.
       FRACTURES  OF THE  NECK OF THE THIGH  BONE,

Are divided, first, into those which happen within the capsular lig-
ament, secondly, into those which occur on the outside of it, or part-
ly in this situation; and thirdly, into such as extend though the great
trochanter.
  With respect to the symptoms of a fracture within the  capsular
ligament, the patient will  complain of severe pain in the  hip; and
there will  be shortening of  the limb.  It was once calculated, that
shortening might  happen  to the extent of from one  to  two  inches
and a half;  but  the observations of Boyer, and of Messrs.  Fade, 
346
PARTICULAR FRACTURES.
 Stanley, and R. W.  Smith*, prove,  that, unless  the capsular liga-
 ment be torn, no retraction of the limb in this last degree can hap-
 pen.   The extent of the retraction will also depend on whether or
 not the reflection of the capsular ligament over the neck of the bone
 be torn; for, in the event of its not being lacerated, there will be no
 shortening of the limb at all; neither will there be another  usual
 symptom,  namely, eversion of the limb.  When  the neck of the
 thigh bone is broken, as all the strong muscles attached to the shaft
 and trochanters have a tendency to turn the limb outwards, so as to
 evert the toes and knee, this is a common symptom of the accident;
 but if the  reflection of the  capsular ligament over  the neck of the
 femur happen not to be torn, such symptom may be absent.  When
 the limb is much shortened, we may not  feel  a crepitus; but if we
 draw the limb downwards, and rotate the foot inwards, the crepitus
 will  then  be distinctly felt.   When there is displacement, the great
 trochanter will not form  such a prominence at the side of the pelvis
 as it naturally does;  and if there  be a shortening of the  limb, the
 same process will  be  found te be nearer to  the crista of the ilium
 than in the sound state of the limb.   Another  symptom,  accompa-
 nying and indeed resulting  from the displacement of the outer frag-
 ment, is a great fulness  of the upper part of  the  thigh,  from the
 muscles having their attachments brought  nearer together.
   In a few uncommon examples, the knee and toes are actually turn-
 ed inwards, instead of outwards;  and the explanation  given of the
 fact  is, that the fracture  takes place sufficiently towards the outside
 of the great trochanter, to  prevent the muscles from acting on the
 lower fragment so  as to turn it outwards, while some fibres of the
 glutaeus medius and minimus, yet continuing attached  to the exter-
 nal portion of the trochanter, retain the power of turning it inwards,
 and consequently the whole limb.   This  is one explanation that has
 been suggested; but it is not  considered  altogether satisfactory by
 some very good judges.  It is alleged, that fractures, entirely with in
 the capsular ligament,  are sometimes attended with inversion of the
 limb, and  to such cases the explanation  proposed would manifestly
 not apply.  Besides, as Dupuytren has remarked, why should not
 the great  adductor muscle  be more  than  enough to counteract the
 action of the anterior fibres of the  glutaeus medius and minimus? At
 all events, the cause of the occasional inversion of the limb, when
 the fracture is  completely  within  the capsular ligament, if it  be a
 fact, appears to me not at present  accounted for.
   When the fracture  is on the outside of the  capsular  ligament,
namely, between that ligament and the trochanter major, the retrac-
tion of the limb  is greater,  than in the fracture within the capsular
ligament;  a point, on which Boyer is corroborated by the observa-
* See Dublin Journ. of Med. Science, vol. vi. p. 206. 
        FRACTURES OF  THE NECK  OF THE  THIGH-BONE.    347

 tions of Messrs.  Earle, Stanley, and Smith.   This kind of accident
 is mostly occasioned by the  application of great and direct violence;
 while other fractures, situated within the  capsular  ligament,  are
 usually produced by slighter degrees of force.   The generality of
 cases, which occur in London, are caused merely by the foot slip-
 ping off the curb-stone, or by falls on the hip, not always attended
 with great violence.   The reason  why so slight  a cause is capable
 of producing this mischief,  is,  that, after  the  age of fifty, the neck
 of the thigh bone becomes weak and slender,  and its shell thinner,
 and incapable of affording as  much resistance to force, calculated
 to fracture it, as it did in an earlier  period of life.  It is partly on
 this account, that fractures of the neck of the thigh bone are so fre-
 quent in old people, and partly  on  account of a change in the direc-
 tion of the axis of this part of the bone in them;  for in consequence
 of its greater weakness, it bends upwards, and forms a right  angle
 with the  pelvis,  instead  of sloping more or less  upwards from  the
 trochanter to the head  of the  bone.  Here another  reason is dis-
 cerned  why fractures more easily take place in  aged  than  young
 subjects;  because any force, operating on the  trochanter major,
 will break the  cervix  of the bone  with  greater certainty,  when  the
 trochanter projects very much,  in  consequence  of the above-men-
 tioned  change in the direction of the neck of  the bone.   In  some
 old subjects, in fact, we find the trochanter absolutely higher than
 the head  of the  bone, the neck having  yielded  thus much to  the
 weight of the body.   But the other fracture of the neck of the  fe-
 mur, namely,  that which  takes place further outwards,  or  more
 towards the great trochanter, beyond the external  limit of the cap-
 sule, is generally produced by great degrees of violence; and is not
 particularly restricted to  old  subjects, but presents  itself also in
 young ones.   Therefore, when  great  and direct  violence  has been
 concerned, the patient is  under fifty, the limb a  good deal shortened,
 and  the crepitus readily  perceived, there is ground for suspecting
 that the fracture is on the outside of the capsular ligament, or partly
 on the  outside of it;  for  sometimes  the  fracture  is oblique, and
 sometimes longitudinal, and occasionally it is incomplete, the fissure
 extending only partially through the neck of the bone.   In general,
 we cannot feel  a crepitus in  fractures within  the capsular ligament,
 unless the limb be brought to its natural length; but, when  the  frac-
 ture is on the  outside of the capsular ligament,  a crepitus can  be
 felt with facility.   If the fracture extend obliquely through the tro-
 chanter major,  there may be  little or no shortening of  the limb; for
 there is such an extent of surface in the fractured part of the  bone,
 and such a direction of the fissure, as are  very likely  to  prevent
 this kind of displacement.   In  this case, we perceive a  crepitus,
 but the  foot is not so much turned out as in the other example.
   When the neck of the femur  has been broken, it becomes short-
ened, being more or less absorbed, and the head  of the bone con- 
348
PARTICULAR FRACTURES.
sequently taking a situation, as it were, between the two  trochan-
ters.   This circumstance, having been known by those who  were
looking out for instances of bony union, after fractures of the neck
of the tbi~h bone, led to a dispute on the subject; because, in con-
sequence  of  the  discovery, that, under  circumstances  of disease,
the neck may be shortened, and the head assume a similar position
to that observed after fractures, many examples of what were sup-
posed to be fractures, which had  admitted of bony union,  were re-
jected on this ground.   Hence, also, various specimens, picked up
in churchyards and other places, and  whose histories are unknown,
should not be too readily considered as proofs   of the  bony union
of a previous fracture.
   Fractures of the neck of the thigh  bone are  more  frequent in
women than men,  and  two reasons may be assigned for this  fact;
first, the neck of  the femur in women  is naturally longer and  more
slender than in the other sex;  and,  secondly, as the pelvis is wider,
the trochanters project  in a  greater degree, and are consequently
more exposed to external violence.   In this metropolis, fractures of
the neck of the thigh bone happen either from  the foot suddenly
slipping off the curb-stone, or from falls on the side of the pelvis.
In Paris,  where the pavement is differently arranged, and the curb-
stone is not so common, the accident  is usually produced by falls
on the hip.   When the  neck of the thigh bone  is fractured, and the
fragments are not separated, the reflection of the capsular  ligament
from one to the other not  being torn,  the diagnosis is generally at-
tended  with  some obscurity, because most of the  characteristic
symptoms are absent; for  instance, there  is neither shortening  of
the limb, nor eversion of it.   Yet,  the patient  cannot raise it from
the surface on which it  is deposited—he cannot lift  it up from the
bed; he may, perhaps, contrive to bend his leg  slightly,  but he can-
not raise it up.  Though a degree of obscurity may  prevail at first,
the nature of the case will mostly be apparent enough in  a few days;
for at this period  the reflection of the  capsular ligament often  gives
way, sometimes in consequence of  the patient  moving his  limb too
much, sometimes in consequence  of  the surgeon doing the  same
thing; but, in whatever  way occasioned, it leads to a retraction and
eversion of the limb.
   I have already referred to the rare  case  where the foot and knee
are inverted, and to the  endeavor to account for it  by the  fracture
having taken place in such a direction through the trochanter major
as to leave attached to the pelvic fragment the insertions of the obtu-
rator internus, the  gemelli and pyriformis, which muscles are natur-
ally concerned in rotating the thigh outwards; while the other, or ex-
ternal fragment, is drawTn forwards and inwards by the gluteus medius,
so as to invert the  limb.   This explanation has not, however,  been
deemed satisfactory by some good judges of the subject.  Suppos-
ing the action of the gluteus medius on the  outer fragment to be the 
       FRACTURES  OF THE NECK  OF THE  THIGH-BONE.   349

cause of ihe limb being turned inwards, it is certainly difficult to com-
prehend why  the effect should not be counteracted by  the adduc-
tor, which is  a much more powerful muscle, and always disposed to)
rotate the femur outwards.  Yet,  the  anomaly must, I  believe,
depend  upon  some  peculiarity  in   the direction of the fissure.
Other Explanations have been offered, one of which is founded on
the well-known fact, that when the neck of the thigh bone is broken,
that portion of it which remains connected to the head is sometimes
forced into the  cancellous structure of the  outer  fragment, and is
immovably wedged in it.   Now, if this  were toJiappen in a partic-
ular way, it is conceived that the inversion of the limb might be pro-
duced.  Dupuytren suggested another explanation, which is, that
when the neck of the femur is fractured obliquely, if the inner frag-
ment happen  to be situated in front of the other fragment, then  the
limb may be  turned outward; but if the inner fragment be behind the
other, then the limb may  be inclined forwards,  and the  knee and
foot turned inwards.  This  is a point in surgery still requiring fur>
ther investigation.
   But, one still more  interesting question, relative to  fractures  of
the neck of the thigh bone, has been,  whether  those which are com-
pletely within the capsular ligam?nt, and transverse with respect  to
the neck of  the  bone, are  capable of  osseous union.   The fact,
that bony  union is possible in such cases, is now completely estab-
lished, and almost every museum contains  specimens  illustrative of
it.   Sir Astley Cooper possesses a fine example of it, which I have
examined  more than once at his  house.   The  m: seum of my friend
Mr. Langstaff contains one that is a complete demonstration of such
union, and which, with several interesting drawings in the same col-
let tion, I  have frequently been permitted, through that gentleman's
kindness,  to show to the surgical class of University College.  The
particulars of the fracture  with bony  union are  published in one of
the volumes of the Medico-Chirurgical  Society of London.   The
bony union is complete in tlie shell of the bone; the centre of the
fissure is united  by a fibrous  substance; but the osseous  consolida-
tion of it is perfect at  its  circumference.   The patient died about
two years after the accident.
   Another unquestionable instance of perfect union by bone, after
a transverse  fracture of the neck of the femur, within the capsular
ligament,  is exhibited in the case of Dr. James, an English physi-
cian, who fell from his  horse as he was riding near Bordeaux, and
fractured the neck of the femur; he  recovered from the  effects of
his accident, but died seven months  after it of some  visceral dis-
ease.  On examination, the fracture was  found, by Dr. Brulatour,
an  eminent surgeon of that city, to be united by bone;  and it ap-
pears from the engraving of the part, that it was a transverse frac-
ture of  the  neck, entirely within tl,e capsular ligament.   The  en-
graving is valuable, not  only on account of its showing a perfect
   vol. ii.                   30 
350
PARTICULAR  FRACTURES.
bony union of a fracture  within the capsular  ligament, but also be-
cause it gives us an accurate representation of the diminution in the
length of the neck of the bone, arising from absorption.  Dr. Bru-
latour has likewise  given a view of the size and shape of the head
and neck of the other femur in the natural state.   Thus we are en-
abled to see at once the difference, which has been produced in the
length of the neck of the bone, and in the position of  its head, with
respect to  the trochanters; it being, as  it were, situated  between
them, with scarcely any portion of the neck  remaining.  Dr. Bru-
latour  has also favored us with  a section of the head and neck of
the femur,  which was the subject of the injury.   Several drawings,
in Mr. Langstaff's museum illustrate the  various ways, in which na-
ture attempts  the reparation  of fractures of  the neck of the  thigh
bone.  One drawing exhibits an immense quantity of bony matter,
thrown out by the portion of the neck, or the fragment, nearest the
trochanter major; together with the thickening of the capsular liga-
ment.  Another drawing was made from a  case in which anchy-
losis had taken place :  and a third is a  view of an  oblique  fracture
of the  neck of the femur, in which there would  not be  much, if
any, retraction ;  bony union has occurred at  the outer part of the
fissure, while the rest appears to be united by the fibrous substance.
A fourth drawing shows the efforts which nature has made  to re-
pair the fracture of the neck of the femur, by  throwing out  a vast
quantity of bony  matter.   1 remember the gentleman very well from
whose case the drawing  was made : he  resided near St. Bartholo-
mew's, and met with the injury by falling from the  upper part of his
house into the street; he  lived several years  after the accident, but
was quite a cripple.  The callus has formed a sort of new  acetabu-
lum, which, together with the increased  thickness  and strength of
the upper portion  of the capsular ligament,  enabled the patient to
use the limb in a certain degree.   In one preparation, in Mr.  Lang-
staff's museum, the fracture is  within the  capsular  ligament ; and
the union, by  means of a ligamentous fibrous  substance, retains the
fragments in such close  contact,  that Mr. Langtaff  is of  opinion,
that, if the  patient had lived long enough, the case would have ter-
minated in bony union.   Yet, the process necessary for its accom-
plishment,  is not so easy and sure as that by which  the generality
of other fractures are united.   When the head  of the bone is com-
pletely detached,  doubtless one  circumstance  unfavorable to bony
union is the scanty supply of blood which  it  receives, and which
consists merely of the  small quantity conveyed  to  it through the
vessels of  the ligamentum teres.*  Another circumstance  is the
  * As the fracture is sometimes united by osseous matter, the supply of blood is, of
course, not always inadequate to the purpose.  From the valuable observations of Du-
puytren, Cruveilhier, and Breschet, on the  process by which fractures are united, it
appears that the vessels of the surrounding tissues perform an active part in the work 
       FRACTURES  OF THE  NECK OF THE  THIGH-BONE.    351

difficulty of maintaining the  fragments steadily in apposition  ;  they
are generally disturbed too much, and the  proper apparatus is not
kept on long enough.  In fact,  Dupuytren contends, that, in  conse-
quence of  the disadvantageous  condition  in  which the neck of the
thigh bone is placed for  bony union, the patient ought to be  confin-
ed, and the requisite apparatus  kept applied for a very long period,
that is  to say, from a hundred  and twenty, to a hundred and forty
days.   In  this  country,  surgeons rarely  persist in  maintaining the
limb quietly and in a desirable  posture for  a space  of time at all
equal to what has now been specified.   Mr. Langstaff, who has paid a
good deal of attention  to this subject, is also  led to believe  that, if
the limb were kept  a  sufficient  length of time without motion, the
ligamentous union would generally be converted  into an osseous
one.   The circumstance of the fracture being oblique or transverse,
influences very  much  the facility and chances of bony union; for,
if the case be oblique, part of the fissure will  extend beyond the
external limit of the capsular ligament, and  then admit of osseous
union with as much ease and  certainty as  any ordinary fractures.
   When  transverse fractures of the  neck of the femur within the
capsule do not unite  by bone, they unite by a ligamentous substance;
the capsular ligament becomes thickened  and  strengthened, and lig-
amentous bands extend  from it to  both fragments,  and sometimes
from one fragment to the other.   In a few instances, another mode
of reparation is  established;  osseous  matter  is thrown out  by that
portion of  the fractured  neck which is connected  with the trochan-
ters, and the callus from this  source assumes a shape  calculated to
support within it the end  of the other fragment; in  other words, a
kind of socket is formed in the outer fragment, which,  as well as the
other fragment,  becomes coated with  what is termed the ivory de-
posit, a very smooth hard substance, by means of which friction be-
tween  the two  fragments is lessened,  and motion facilitated; it an-
swers, in fact, the purpose of cartilage.
   With regard to the  treatment of fractures of the neck of  the  fe-
mur, I may remark that, at one period, several surgeons considered
the chance of bony  union so  hopeless, when the fractures were en-
tirely within the capsule, that they did not  deem  it worth while  to
direct the treatment expressly to the  attainment of such union, and
they merely put the  limb for two or three  weeks on a double inclin-
ed plane, or on pillows or bolsters laid under the ham.   Such,  in-
of reparation.  But, as Mr. Mayo has justly noticed, these tissues are excluded by the
untorn synovial and capsular membranes from communicating with the  fracture.
" They are sometime;!, indeed, seen to make the ordinary effort towards reparation of
Ihe adjacent fracture.  Thus a portion of an ossified provisional callus is often met
with external to the attachment of the capsular membrane to the neck of the femur.
Hut the effort is ineffectual; the callus cannot reach the fracture, whether it remains
entirely disunited, or is glued together by an exudation from the ends of the bones."
See Outlines of Pathology, p. 9. 
352
PARTICULAR FRACTURES.
deed, is the practice of Sir Astley Cooper, who places a pillow or
bolster under the ham, and if the patient be very old, and the frac-
ture attend to with symptoms denoting its situation  to be within the
capsular ligament, all idea of subjecting the case to very long con-
finement is renounced.  At the end of two or three weeks,  the pa-
tient is allowed to get up and use crutches.   Other surgeons do not
pursue this method;  and, having greater confidence in the possibility
of obtaining  bony union,  they recommend  the confinement to be
longer, and  the  fracture to be more carefully  put up.   With  this
view, some of them  employ the double inclined plane, and apply
the pelvis strap so as to make the pelvis and apparatus, as it were,
one piece, between the two parts of which  no motion can happen.
In France, Dupuytren used to make a double  inclined plane  with
pillows, duly arranged under the limb; but the objection to this  plan
is, that there is nothing to prevent the patient from changing his po-
sition, or the limb from assuming another posture; and if Dupuy-
tren's method has  the recommendation of simplicity, it is not a
good one in other  respects, since it cannot be  depended on for
keeping the  limb steady.   In University College  Hospital, frac-
tures of the neck of the femur are generally  treated with Default's
long splint, applied as already explained.  An  ingenious treatment
was  proposed by Hagedorn, the  principle of which was  to make
the sound limb the part on which a long splint might be fixed, to the
extremity of which  a foot-board  for the other  limb  was attached.
Thus the  surgeon had a fixed surface on  which  the foot of the in-
jured limb could  be  placed and fixed  in the most desirable position.
In truth, the right principle in the treatment always consists princi-
pally in bringing down the limb to its proper length, and regulating
the position of the foot; for nothing of importance can be done  with
splints, except inasmuch as they  may serve for regulating the posi-
tion  of the limb, and  keeping it steady.    Hagedorn's apparatus has
a slipper,  and, by placing the foot in  it, any  direction  may be given
to this part of the  limb,  considered  advantageous.  Ingenious as
Hagedorn's plan is,  it has not been much  employed, chiefly  because
it is found to be  very irksome to the patient.  In America, Profes-
sor Gibson has taken the trouble to  modify the apparatus,  by  car-
rying the splint as high as  the axilla, and applying to the injured
limb a splint which  extends also as high as the armpit.
   [Our author jjkes  us the different  modes of treatment  of  fracture
of the neck  of the thigh bone within the capsular ligament, nnd leaves
us to exercise our own skill  in  selecting  between them.  The great
fault 1 have to find with his writings is, that be seems to have no de-
finite method of  bis own, or to which  be gives  preference, as every
sound practical man  should .have.
   Sir Astley Cooper,  in his Lectures, remarks that in all  the exami-
nations he  has made, in cases of fracture within 'the capsular  liga-
ment, he has seen but one, in which, after a transverse fracture,  Jong
union had taken  place.  He says, " he does  not  mean  to deny the 
     FRACTURES OF THE NECK OF THE THIGH-BONE.      353

possibility of a bony union, or to maintain that it cannot lake place;"
certainly he does not, when as he admits, he has seen one case, where
in a transverse fracture within the capsule, there was a union by bone ;
but be says " it  is an exceedingly rare  circumstance."   It  is rather
rare, that the above fracture admits of the osseous restoration, but the
treatment  Sir Astley recommends, because  the  union  must  be  liga-
mentous ex necessitate, would  produce such an union  in  any other
fracture.   It is, in  fact, the very treatment  to produce a false joint,
and defeat  the legitimate purpose of the surgeon.   lie says, " a pil-
low is to be placed  under the limb lengthwise, then a second one is to
be rolled up  and placed  under the first, so as to  flex the leg  upon the
thigh.   The patient is to remain in this state for ten  days or a fort-
night,  after which he is allowed to rise and  sit in a  hiarh chair,  in or-
der to prevent much  flexion of the  limb.   In a few days  more,  he
should begin to  walk with crutches; and then  in  a few months  he
will be able  to lay  tbe  crutches  aside, and  walk with the  help of a
stick,  and high heeled shoe".   After such treatment as this, no wonder
osseous union seldom occurs.
   Sir  Astley's reasons why a bony union cannot  occur, are, First, the
difficulty of preventing motion of the part; and this is unquestiona-
bly one of the chief obstacles to union ; for the parts are so surround-
ed by  powerful  muscles,  that  the slightest  movements of the  body,
even tbe involuntary motions of coughing and  sneezing, tend  to de-
Btroy  the coaptation.
   Secondly, the want of apposition, which  is involved  in the reason
j.u-1 mentioned.
   Thirdly, continued  pressure is essential, in  order  that  an ossific
union  may take place ; and this it is difficult to accomplish.
   Fourthly, there is an effusion of  synovia, which  by  distending the
capsule, separates  the fractured  surfaces, and   thus prevents union.
All these circumstances are entitled to weight, as reasons why  we do
not get the desired  union, though  tbe chief obstacle  in the way of
 success, is found in the first, the motion, which  interrupts the efforts
of nature.
   L'ut, that  which Sir Astley assigns as the principal  reason,  has in
my mind little or no weight; 1 mean the deficiency of ossific inflam-
 maiion.   The circulation of  the  general system communicates with
 the bead of tbe  bone, it is true, only by the vessels connected with
the Ii^amentum teres ;  yet it seems  to be forgotten, that tbe vessels in
 all parts of the  body,  have the  inherent  power of enlarging to meet
the exigencies of the case.   We see this fact demonstrated, in a most
beautiful manner, in ulcers of the cornea ;  in the mammary and  ute-
rine arteries, when these organs are called  into action during  gesta-
tion and lactation ;  and the same great  law is exhibited in all  cases,
 where the  large trunks of arteries are ligated,  and smaller  collateral
 branches are required to perform extra labor.   Now, has it ever been
 proved by Sir Astley Cooper, or any other person, that the arteries
 communicating with the bead of the  femur through the ligamentum
 teres, form an  exception, a solitary  exception, to that great law?  My
own conviction is, that the great obstacle to ossific union, is the want
Of a steady coaptation  of the fractured surfaces.
                              30* 
354               PARTICULAR FRACTURES.
   But enough of this disagreement with others.   In  the first  pFare,
 there is a difficulty in diagnosticating  with absolute certainty,  the ex
 act  location of tbe fracture-   We have the transverse fracture entire-
 ly within the capsular ligament;  and we have it also partly within and
 partly without, and  between these there is a difficulty of decision.
   Whenever there is any doubt,  as  to whether tbe fracture  be partly
 without tbe capsule, we should always proceed with a treatment which
 shall keep the parts in  coaptation, and if the constitution be good, we
 may expect an osseous  union.
   When tbe fracture is diagnosticated to be entirely within tbe cap-
 sule, if the patient be sixty or  under, we should always aim at a union
 by bone, unless tbe  general health of the patient forbid  the confine-
 ment.   If the patient be over sixty, and the constitution be good, then
 give him the  chance for an osseous union.   I have in  my museum,
 at the College of Physicians and Surgeons, a  perfect specimen  of
 union  by bone,  in case of a transverse fracture  within  the  capsule,
 taken from  a  female who was sixty four years of age when  the acci-
 dent occurred.
   It often happens,  when we have fractures within  the capsular  liga-
 ment, in subjects over sixty, that the bone is so soft and  friable as to
 be crushed  into several pieces.  In  such cases, I should avoid the
 confined mode of  treatment, and  follow that recommended by Sir Ast-
 ley Cooper.
  If then, I have  a simple fracture,  at the neck  of the  thigh bone
 within the capsule, if the patient be not too old,  and the constitution,
 be good, I treat my patient  with a  view to an osseous  union : if,  in
 the event, I fail, I have done my  duty.
  After  one of these fractures, I allow the patient to remain  in a com-
 fortable position for ten or fifteen days, until  the more active  inflam-
 mation  has  passed, and  then I place him in the tight dressings.  A
 roller is applied  from the toes to tbe hip, in order  to support the pnrts ;
 then a broad cushioned  belt  is carried  around  the pelvis, and over
 the  trochanters.   I commonly use  Desault's splint, as  modified by
 the late Dr. Physick;. or the same splint as  modified by  Prof. Gibson-
 The fractured limb  is brought  down to tbe  same  length as tbe well
 one, and maintained by the above apparatus in a  position correspond-
 ing with its lellow.  The time required  for  ossific union  varies from
 Bix weeks to three months.
  I  have been led  to these remarks,  mainly because of the unfortu-
 nate influence which Sir Astley Cooper's opinions, upon this subject,
 were exerting upon practice, and  upon members of the profession.
 I hold his opinions upon most surgical subjects, as commanding tbe
 highest respect,  and as  at tbe head of authority :  still I cannot believe
 that  a  thing  is  so,  simply because^ Mr. Cooper, or any other man,
 nia'<es the assertion.
  There has heen going on, for the last ten years, a  most vexatious
 and  malicious law  suit  in  this coumry, against  a  highly  respectable
 surgeon, because he  treated a patient, a female, forty-three or  four
 years old, for fracture wiibin tbe cs'p-ular ligament, in a manner  not
 recommended by Sir Astley Cooper, and succeeded in  obtaining an
 osseous union.  In about three months, she was able to  walk,  both
limbs being  of the same length.  When payment for services was de- 
t
                FRACTURES  OF THE  PATELLA.             355

manded,  it was refused, upon the ground thnt there hid been  no frac-
ture, and that  the treatment had been mere sham.   Tbe surgeon was
sued for mal practice, and Sir Asiley Cooper  was quoted, to  prove
that if there bad been such a fracture, there eon/d have been no  union
by bone,  and that the limb would necessxrily have been shortened and
deformed.  Tbe patient  died  some seven years after tbe accident;
and the bone presented ample evidence of fracture within the capsu-
lar ligament, and  osseous union : and  then,  i.nd not till then,  the
poor surgeon,  after having been injured  in reputation, and ruined  in
property  by tbe suit,  was permitted to escape the fangs of a most ma-
licious and unrighteous prosecution.—Ed ]
  When the lower part of the thigh bone is fractured,  or when  the
fissure goes into the  knee joint, the extended  position  of the limb
is often preferred, because it  keeps  the head of the  tibia in contact
with the  condyles of the femur, and  thus has a most useful opera-
tion in keeping them steady.   Were it not  for this consideration,
we should  be  inclined to advise the  bent  position  of  the  limb, in
order to  relax the gastrocnemius and  the  popliteus, which have a
tendency  to draw the lower fragment  towards  the ham;  but  Sir
Astley Cooper, whose experience and judgment are equally great,
found, that more advantage was derived from the effect of the ex-
tended position in  bringing the head  of the tibia in contact  with the
condyles of the femur, than from  the relaxation of the  muscles  in
question.   In  such a case, lateral  splints should be applied, in  or-
der to afford due support to the broken part, and keep it motionless.
In these  cases, a considerable degree of swelling generally comes
on, so that for a few days the surgeon is obliged to defer the use of
splints, and aim at the reduction of the inflammation by means of
leeches, venesection, cold  applications, &c.

                 FRACTURES OF  THE  PATELLA

Commonly happen in the  transverse direction, and  are caused  by
the  powerful  action  of the extensor muscles of the  leg.  The cir-
cumstance  most frequently causing the bone to be fractured in this
manner, is that of a  person making a violent effort to save himself
from falling backwards, when he has lost his equilibrium;  for then  the
extensors of the leg  act with  immense force to keep the femur and
the  pelvis forwards;  and  as  the knee is always somewhat bent at
the moment, only the lower portion of the patella is actually in con-
tact with the condyles of the femur,  over which the  muscles break
it transversely, as already mentioned.   However, this is not the on-
ly \v;.y in which  a fracture of the patella  may be  produced,  for
sometimes  the bone  breaks  while the  leg  is  perfectly extended.
When we hear of cases, in which the thrust of a gorget into the blad-
der, in lithotomy, made the muscles  of  the thigh act so violently as
to break  the knee-pan, we may conclude, that ihe accident happen-
ed when  the knee was Lent,  because the position,  in  which  the 
t
 356                PARTICULAR  FRACTURES.

 patient is bound  for that operation, would make this tolerably cer-
 tain; but it is alleged, that the patella has been fractured by the vio-
 lent action  of the muscles in epilepsy, even when the limb  was in
 the straight or extended posture.   The  patella  may  be  broken in
 the longitudinal,  or  perpendicular  direction, by  direct  violence.
 Not long ago, a case occurred  in the Hotel Dieu at Paris, where
 the patella  was fractured both in tbe longitudinal and transverse di-
 rections, the bone being split into nearly equal  quarters; the acci-
 dent was, of  course,  produced  by direct violence, for I scarcely
 need observe, that such a fracture could not have  been  the  result
 of the action of the extensor muscles of the leg.
    When the patella  is  fractured, the symptoms  vary according  to
 circumstances; in the first place, whether tbe  tendinous expansion
 covering the bone  be lacerated  at  the same time that  the  fracture
 takes  place, is a circumstance making some  difference; secondly,
 much  will  depend upon the degree of laceration of the tendinous
 covering of the bone.   When both these parts are torn through, the
 upper fragment may be retracted a considerable distance up the thigh,
*as far, perhaps, as four or five inches;  but if they are  not lacerated,
 the fragments will hardly be separated at all.   Of course, while the
 fragments are much  apart, we are  not able to perceive a crepitus;
 but, if we  extend  the leg, so as to relax the  extensor muscles, we
 may push  down the upper fragment, and fbring it into contact with
 the lower one, and then  a crepitus will be immediately distinguished.
 When attempts are made by the patient to bear upon the limb, it
 will be found, that he cannot support  the weight of his  body upon
 it; and he falls forward  on his knee.   If the upper fragment is com-
 pletely detached  from the lower one  by rupture  of the tendinous
 expansion covering them, the distance between them may also be
 increased by bending the knee; so  that, in general,  when the frac-
 ture is transverse, the case is evident enough.   But, in  a longitudi-
 nal fracture, the displacement is not so manifest, and  more attention
 will be requisite to detect the real nature of the accident;  yet if we
 relax  the, extensors, we may generally feel a crepitus  in this case
 ajso, and with no great  difficulty, notwithstanding there may be con-
 siderable swelling, in consequence  of the species of violence that
 has produced  the  accident, namely, a direct  blow, or kick; for
 longitudinal or perpendicular fractures, of the  patella, as I  have al-
 ready explained, cannot happen from  the  action  of the extensor
 muscles  of the leg, but  always  require for their production  direct
 externa] violence.
    The treatment consists in paying attention to twTo circumstances:—
 one is to relax the extensor muscles of the leg as much as possible;
 the other is to bring the upper fragment into contact  with the lower
 one, and keep it so.  Now, the first object, namely, the relaxation
 of the extensor muscles of the leg, requires that their lower attach-
 ments should be put as  near to their origins as possible.   The rec- 
FRACTURES OF THE PATELLA.
357
tus, therefore, is to  be relaxed by bending the thigh on the pelvis,
by which the patella and  the upper part of the brim of the acetabu-
lum and the anterior inferior spinous process of the ilium, the inser-
tion and origins of this muscle, are brought into as much approxima-
tion as can be effected by position.   Now this  will  partly relax the
rectus, but not  the vasti and  cruralis, which require the leg to be
extended.  For maintaining the limb in this position, the surgeon is
to place the leg and thigh on an inclined surface, rising gradually and
regularly all the way from the tuberosity of the  ischium to the heel;
the trunk being also raised on another inclined  surface, so as to in-
cline the front of the pelvis towards the thigh.   The other circum-
stance to be attended to, or that of bringing the fragments  into ap-
position, and keeping them so, is fulfilled by pushing the upper  frag-
ment  down  into its proper situation, and  applying a  roller to the
lower part  of the thigh, just above the upper fragment.  Some sur-
geons put a few circles of a roller above the patella, and others be-
low the knee, after which the upper and lower ones are  laced to-
gether with  packthread.   Some years  ago, it was the custom,  after
the limb and  patella had been put into the proper position, to apply
a roller a few times round the thigh,  above the  upper fragment, and
then to finish the bandage by passing the same roller round the knee,
in the form of a  figure of 8; but this  fie;ure-of-8 direction of the
bandage, though it may  look well, is of no real use.  Sir Astley
Cooper first applies a leather strap to keep tic upper fragment near
 the lower one, and  then applies another strap, which pises  from
the first, down one side of the leg, across the scle to the oilier  side,
along which it ascends to the circular strap again.
  Dupuytren employs the uniting bandage and a compress, which
seem  to answer very well; indeed, a case is related by Sanson, which
he saw treated  by  Dupuytren  with these simple means, where the
union was so strong, that  when the patient afterwards met with an ac-
cident, in which the extensors of the leg were made to act violently,
the united part of the bone did not give way, but the ligamentum pa-
tellae.  Putting the limb in a fracture-box is a convenient mode of keep-
ing  the leg and thigh steadily in the proper posture.   Any of the
plans, however, which I have enumerated, may  be practised  with
success; but it should always be remembered,  that  the maintenance
of the limb in the  right position is of  still greater  importance, than
any roller or apparatus for confining the upper fragment  near the
lower one.
  Transverse fractures of the patella generally unite by a fibrous or
ligamentous substance, and not by bone.  There have been instan-
ces, however, in which a union has  taken place by bone;  but they
are  rare.   On  the other hand, longitudinal fractures of  the patella,
occ.sioned by direct blows,  frequently unite  by  osseous  matter.
In the museum of University College, is a preparation taken from a
coachman,  who fell  from his coach-box, when his knee  came v io- 
358
PARTICULAR FRACTURES.
lently into contact with the pole of the carriage; the consequence
was a  comminuted fracture  of  the  patella.   Osseous  union  has
taken place.   Unfortunately, however, the case had an unfavorable
termination;  for, too much pressure having been employed, inflam-
mation of the knee joint came on, and the man ultimately died.   In
the same collection is  another specimen of a transverse fracture of
the patella produced by direct external violence.   The apex, which
was broken  off, is united again by  means  of  bone.   Mr. Gulliver
has recorded two cases of bony union.  The first is that of a sail-
or, who fell on his knee from' the maintop of a brig:  the second is
that of a soldier, whose patella was fractured  by a gun-shot.   Mr.
Gulliver also broke the patellae of rabbits and dogs; first by blows,
so as not to  divide the aponeurosis, which  covers it, and, in  such
cases, the union was osseous; and secondly, he cut the bone and apon-
eurosis  through with cutting forceps, and under such  circumstances,
no bony union followed.  His cunclusions are, that when the aponeu-
rosis is completely divided, as  in fractures of the patella from the
violent action of the extensors of the leg, bony union is not  to be
expected; because, in such cases, it is impossible to keep the  frag-
ments in accurate contact; and that osseous union is simply the ef-
fect of the immovable  coaptation  of the fragments, the provision for
which, in certain fractures from external violence, is the integrity of
the aponeurosis in front of the bone.*  It sometimes happens,  that,
after the cure of a fractured patella, the patient meets with an acci-
dent, in which the extensor muscles of the leg act with such violence
that they lacerate the ligamentous  substance, which is the usual bond
of union in  transverse cases;  and then even the skin  and synovial
membrane may give way, and the knee receive  injury of  so serious
a nature as to call for amputation.   Some preparations  in the mu-
seum of University College prove, that a fracture of the patella
may be followed by severe disease  of the knee joint;—as inflamma-
tion of  the  synovial  membrane,  abscesses, and absorption  of the
cartilages.

          FRACTURES OF THE  BONES OF THE LEG.

  We might suppose,  on  looking at these bones, and seeing one of
them so strong  and the other so slender, that the fibula would most
frequently be fractured; this is not the case.   The  tibia, strong as
it is, is oftener  broken than the fibula, and one  reason of this  is  its
superficial and  exposed situation in  front  of  the leg.   In fact,  its
anterior surface  is merely covered by the  integuments.   Another
reason is, that  the  tibia receives  all the weight of the body when a
person leaps, or alights with his foot  forcibly  on the ground.   The
* Edinb. Med. and Surgical Journ. Jan. 1837. 
FRACTURES
OF  THE  BONES OF THE LEG.
359
fibula is covered to the extent of its two upper thirds by thick mus-
cles, and the rest of it may be said to be very much protected  by
the tibia itself.   Indeed, the peronaei muscles alone are sufficient to
guard it from the  effects of ordinary degrees of violence directed
against the outside of the leg.
   When the tibia is broken singly, the  injury is  generally  caused
by direct  violence, more especially if the  fracture happen at any
point of the two upper thirds of the  bone.   The  fracture is then
usually produced by a blow, a kick, or the passage of a wheel of
a heavy carriage over the limb.  The lower third of the tibia may
be fractured either by direct or  indirect violence, or  as the result
of what the French surgeons call a contre-coup.   A fracture of the
upper third of the tibia is frequently transverse; but one situated in
the two lower thirds of the bone is generally oblique.   When the
tibia is the  only  bone broken, and the  fracture is  in  the upper third
of it, some attention is necessary to discover the nature of the ac-
cident, because  there is no change  in the  shape of the  limb;  for the
fibula, being perfect, acts as  a  splint, so that there  can be no short-
ening of the member, while the extensive surface of a fracture, in
this  situation, tends equally to prevent both retraction and displace-
ment.   However, the slightest inequality of the  tibia, may always
be detected by passing the finger along the anterior edge or spine
of that bone, when, if there be a fracture, some projection or irreg-
ularity, at the part where the fracture is situated, will be perceived.
On moving  thejankle and knee rather freely, we shall also perceive, that,
exactly in  the place of the solution of continuity, the  bone, instead
of being firm and unyielding, has a degree of motion in it, or yields
when pressed upon.   If both  bones  should  happen to  be broken,
then the case will be evident enough, as a change will  be noticed in
the shape of the limb, an angular deformity, the  heel  being  drawn
more or less  backward and upward  by  the muscles of the calf.
We shall also observe a  shortening of the limb, and that the foot is
twisted either inwards or outwards.   Were any other  circumstance
necessary to  convince  us of  the nature of the accident, we  should
have such a criterion in the very distinct crepitus, that could be felt
without the least difficulty.
   When the fracture is situated at  any point of the lower two thirds
of the tibia, the fissure through the bone will  frequently extend ob-
liquely from above downwards and from behind forwards.   Hence,
the extremity of the upper  fragment will be very sharp, and  likely
to protrude through the skin, making the case a compound fracture.
When the fibula is broken, as well as the  tibia, the  latter  bone gen-
erally gives way first, and then the weight of the body being trans-
mitted to the fibula, this  bone also breaks.  Such is the explanation
offered by  Dupuytren, as that which applies to the majority of cases;
but sometimes both bones are fractured at once by direct violence,
as happens when the wheel  of a heavy  carriage passes over the
limb. 
360
PARTICULAR FRACTURES.
   Although the fibula is, on the whole, less frequently broken than
the tibia, still the accident is common enough; so common, indeed,
that Dupuytren calculates,  that  fractures  of the lower third of the
fibula amount in number  to one third of all fractures of the legs.
Fractures of the  upper two thirds of the fibula are generally caused
by direct violence, while those of its lower third are most frequent-
ly occasioned by a forcible twist of the foot.  The twist most com-
monly happens in the direction outwartls,  and, when this is the case,
the fibula usually breaks  from two to  four inches above the external
malleolus.   When the fibula is broken, in consequence of the foot
being twisted outwards, the inner edge of  the sole is in contact with
the ground, and the upper  end of the lower  fragment inclines  in-
wards towards the tibia.  The fibula may also be broken by the
foot being  twisted inwards, in which  event, the deformity will be
different, for the  outer edge of the sole will be against the ground;
the sole itself will be  turned  inwards;  and  the upper  end of the
lower fragment will be directed outwards, away from the tibia.
   The generality of fractures of the leg  may be conveniently treat-'
ed in  the slightly flexed position, with the limb supported on M'In-
tyre's apparatus; or the leg may be placed on Amesbury's or  some
other double inclined plane, and supported with lateral splints.   The
bent  position is  by far the most comfortable to the patient, and it
has the  advantage of relaxing  the  powerful muscles of the calf.
However,  when  the fracture  is situated high up, near the knee, the
limb may be kept in the  extended  position, which, as  Sir Astley
Cooper well observes, converts  the  condyles of the femur into a
surface, against which the  upper  fragment can be steadily  main-
tained.
   Fractures of the upper part of the fibula generally unite without
any permanent ill consequences, even though they may be neglect-
ed, and taken little care of.  No doubt,  ma ly of  them are never
detected at all, in consequence of being unattended  with displace-
ment.   But, fractures of the lower part of  the fibula require more
caution; for if they are not rightly  managed,  the patient will some-
times  be a cripple for  life, the  foot remaining distorted outwards,
and the individual being obliged to walk on the inner  malleolus, in-
stead of on the sole of the foot.
   Dupuytren adopts a simple and effectual  plan for the treatment of
those fractures of the fibula which  proceed from a violent twist of
the foot outwards.   The  whole of  his apparatus  consists of two
rollers, a splint about two feet in length, and a pad  stuffed with oat-
en chaff, much thicker at one end than the other.   The  pad is ap-
plied  to the inside of the  leg, with its thick end  downwards, and
then the splint is put on,  which, by extending beyond the inner edge
of the sole, makes a  fixed point at a convenient  distance from it,
against which the foot is  kept inclined inwards by means of a roller.
The splint is first secured  on  the part with a few turns of the roller 
DISLOCATIONS OF  THE  LOWER  JAW.
361
round the upper part of the leg.  If tbe fibula is broken by a twist
of the foot inwards,  Dupuytren applies the splint and  pad on  the
outer side of the leg.
   Some fractures of the leg have  been treated successfully  with
splints made on  the principle of the fracture-box,  and the  lateral
parts of  which admit of being  let down, or put up, by  means of
hinges.   Assalini's splints are  thus constructed.   If they are em-
ployed,  the limb must then be kept in the  extended position.  Cer-
tain  compound fractures are very conveniently dressed  when such a
splint, or  a  common  fracture-box, is  employed.  In University
College Hospital,  M'Intyre's apparatus is  commonly   preferred to
others, as being more simple, requiring no additional splint, keeping
the limb perfectly  steady, and, what is of high importance, allowing
a  great  part of its surface to be uncovered, and the wound, if any
be present, dressed, without the slightest disturbance  of the  frac-
ture.  Greenhow's apparatus likewise appears to me a highly meri-
torious one for the preceding objects;  but less simple and more ex-
pensive: with it the whole of the leg may be uncovered,  and a wound
dressed without moving the fracture in the  slightest degree.

                FRACTURES  OF THE  OS  CALCIS

Is a rare accident; the  fracture always occurs  behind  the junction
of this bone with the astragalus.  The treatment consists in relaxing
the  muscles of the calf, and applying splints and  bandages for the
purpose of preventing  motion of  the  ankle.   In the museum of
University College is a specimen of a fracture of the os calcis united.
            PARTICULAR DISLOCATIONS.

             DISLOCATIONS OF  THE LOWER JAW.

While the mouth  is shut, the lower jaw cannot be dislocated: but
when the teeth are separated, and the mouth widely open, the con->
dyles pass  forwards on  the  eminentiai articulares; and  while they
are in this position, if there  be any spasmodic  action of the depres-
sors of the chin, or of the external pterygoid muscle, to bring them
a little  more forwards, they  will slip under the zygomatic processes,
and thus a dislocation will be produced.   The condyles of the low-
er jaw  can be dislocated in  no  oilier direction than  that  forwards
under the  zygoma; and  the accident  may happen either in  the man-
ner I have described, or in consequence of some external violence
acting upon the body of the bone, at a.time when the mouth is opeq,
   vol. n.                  31 
362
PARTICULAR  DISLOCATIONS.
In fact, at that period, a very slight force, applied so as to depress
the chin, will  make the  condyles glide  under the zygomas; and
hence, dentists, if they are rough and careless in their  proceedings
for the extraction of the teeth, may dislocate the lower  jaw.
   The dislocation can only take place  forwards under  the zygoma;
and this is true with respect to the two kinds of dislocation to which
the lower jaw is liable:  one in which  both the condyles  are displac-
ed, and the  other, the particular  case  where only one of them is
dislocated; which is less  common.   The lower jaw,  however, is
subject to another kind of accident, attended with a partial displace-
ment of it, namely, the case in which the condyle of one side slips
out of  the inter-articular  cartilage; this is called a  subluxation  of
the jaw;  the condyle does not quit the capsule, but merely the in-
ter-articular   cartilage;  the  jaw becomes   motionless,  and  the
mouth continues  slightly open.  We meet, then, with  three cases,
the dislocation oj  both condyles;  the  dislocation of one; and the
subluxation,  or mere displacement of one condyle  from the inter-
articular cartilage.
   The symptoms of a complete dislocat'on are the following:—In
consequence of the position assumed  by  the  bone,  when  the con-
dyles  are thrown forwards out of the glenoid cavities, the  mouth
must necessarily remain open,—it  cannot be closed; for this would
be prevented  by  the coronoid processes  touching the  cheek bone.
The power of speech is of course considerably impaired, the pro-
nunciation of the labial  consonants  being impossible.    After the
bone has remained  unreduced for  some time, it is true, the mouth
will become rather less  widely  open; but still  it cannot be closed
on account  of the  mechanical  impediment to which I  have allud-
ed.  The chain  is considerably  lengthened, the  cheeks stretched
and  flattened, and the lower teeth, if they could be brought up  as
high as the upper ones, would be  much  in advance of them.   In
consequence of the irritation of the parotid  gland,  there is a pro-
fuse secretion of  saliva,  which  is incessantly  dribbling out of the
mouth.   In addition to  the preceding symptoms, a depression may
be perceived just in  front of the meatus auditorious externus, occa-
sioned  by the removal of the condyle  from  its place.   When the
dislocation is restricted  to one side, of course, the  depression will
be perceptible only in front of the  corresponding ear.
   When the case is a dislocation of only one condyle,  we may no-
tice, especially in thin  persons, a slight  distortion  of  the chin  or
mouth, an  inclination of it towards  the opposite side; but, in  fat
subjects, this kind of  deformity may  be so slight as perhaps not  to
excite attention.  At one time, it  was supposed, that an unreduced
dislocation of the lower jaw would be  fatal: it is certainly a very
distressing occurrence;  but there  is no truth in the foregoing state-
ment, for  cases are on record  of individuals, who lived  many years
in this  pitiable condition. 
             DISLOCATIONS OF THE LOWER JAW.          363

   In the treatment there are two indications: to reduce the displaced
part or parts of the bone, and to keep them reduced.   These indi-
cations apply indeed to every dislocation, which has not existed too
long to render  their fulfilment totally  impracticable.   The  manner
of reducing a common and complete  dislocation of the lower jaw is
very simple.  The mouth is already open, so  that  there is  space
enough between the teeth to admit of the introduction of the thumbs
into the mouth.   The surgeon, recollecting the principle explained
in my  general observations on dislocations, endeavors to make the
dislocated  bone a lever  for reducing  its head, or its condyle; he
therefore introduces his thumbs into the mouth, and applies  them on
the molar teeth;  in short, they are to serve as the fulcra, on which
he is to make the bone  move: his fingers are next  applied under-
neath the chin to the body of the bone;  he now pushes the condyles
with his thumbs downwards and  backwards, at  the same time that
he brings the chin upwards and forwards with the  pressure of his
fingers; and as  soon as  the condyles  are  thus extricated from the
zygomas, the temporal and  masseter muscles act so quickly  and sud-
denly  in pulling them back into the glenoid cavities of the temporal
bones, that if  the surgeon were not very prompt in moving his
thumbs towards the cheeks, out  of danger, they would be  severely
bitten.   It  is on this account, that some practitioners  usually put on
a pair of thick glove=, before proceeding to reduce a dislocation of
the lower jaw.   Indeed, the rapidity  is very great with  which the
bone returns into the articular cavities, when the condyles are  extri-
cated from  their confinement under the zygomatic processes.   Then
the second indication, or that of keeping  the bone reduced,  is ac-
complished by a very simple plan: as there cannot be any displace-
ment of the  condyles, while the mouth remains closed, it is  usual to
apply,  directly  after the reduction, the four-tailed bandge,  in order
to keep the mouth  in  this  safe and desirable  position.   The two
front tails of the bandage are brought  to the back of the  head, and
the two posterior ones applied  to the forehead.  The  bandage is
worn for about  ten days, and the patient is restricted  to spoon diet,
and directed  to avoid conversation.   If there  be a  great  deal  of
swelling, bleeding, and other antiphlogistic measures will be advisa-
ble.   When only one condyle is displaced, and pressure made with
the thumbs  on the molar teeth of both sides of the jaw, sometimes
we cannot succeed in  effecting the reduction; and I  therefore rec-
ommend Mr. Hey's advice not to be  forgotten, which is, to  apply
the thumb only  on the side  where the  dislocation has taken place,
and to  let the lever-like  movement be directed particularly to the
displaced condyle, and not  to the other.   By attending to this max-
im, I lately reduced, without much  difficulty, a  dislocation of one
condyle in a woman brought to my house by my neighbor, Mr. De-
lisser.
  In the subluxation of the loioer jaw, when the condyle is thrown 
364
PARTICULAR DISLOCATIONS.
out of  the  inter-articular  cartilage, the jaw is  rendered  motion-
less, and the mouth cannot be entirely shut.   It is an accident that
does not call for the interference of a surgeon, as the condyle  us-
ually  returns into its  place again in a few  minutes, without  as-
sistance.
   When the reduction of a dislocated  jaw is attended with extra-
ordinary difficulty, we should  have recourse to bleeding and  other
means of weakening the muscles.
   A person, who has once dislocated his jaw, will always be  liable
to the  accident  again  from slight  causes;  and  sometimes  merely
laughing, or yawning, will  bring it on.

               DISLOCATIONS  OF THE  CLAVICLE

Are much less common than fractures.    The clavicle may be dis-
located either at its sternal extremity, or at  its junction with the  ac-
romion; but  the  dislocation of the sternal  end  is  more frequent:
first,  because that end of the bone is   naturally  more  moveable;
and, secondly, because its  ligaments are considerably weaker, than
fhose which tie the other extremity of the clavicle to the acromion.
The accident, when it occurs,  mostly  happens in children and wo-
men,  in  whom the  ligaments are weaker,  and the articular cavity
shallower, than in male adults.
   In  what direction does the dislocation of the  sternal  end of  the
clavicle usually take place?   It happens in most cases forward;  the
dislocation backwards being so rare, that Sir  Astley  Cooper, with
all his  experience,  has only met with one example of it, and that
was not produced by external violence, but was the  result of  great
deformity of the chest and spine, whereby such a change was  made
in the direction of the whole trunk, and of the clavicle in particular,
that its sternal end was thrown backwards.   One curious result of
this case was, that the oesophagus was dangerously pressed upon by
the dislocated  end of the clavicle, which  the surgeon was obliged
to saw off to save the patient's life.   The  dislocation of the sternal
end forwards is much more frequent, and may occur in  two ways;
either from a fall on the shoulder, or from the application of exter-
nal violence, which,  by pushing the acromion suddenly and  consid-
erably backwards, gives a disposition to the sternal end   of  the cla-
vicle to start forwards in the same proportion.  The nature of  the
case is obvious, from the superficial and prominent situation of  the
bone.   The  accident, if complete,  is  attended with  laceration of
all the ligaments and part of the tendinous attachment of  the sterno-
mastoid  muscle.  The treatment  consists in the  application of a
wedge-shaped cushion under the axilla,  to make the humerus act as
a lever in propelling the  shoulder  outwards; in the employment of
a bandage and sling to confine  the arm in a position, in  which  the
elbow and fore-arm are duly supported, and held rather backwards, 
DISLOCATIONS OF  THE  CLAVICLE.
365
while the shoulder is  inclined a  little forwards; and  in  putting a
compress on the sternal end of the clavicle, and  keeping it  there
with the bandage.
  The acromial end of the clavicle can  be dislocated only in one
direction,  which is upwards.  It  cannot be  dislocated downwards;
for  the root of the  coracoid process  of the scapula, and the liga-
ment extending from this  process to the acromion, resist  a disloca-
tion downwards; but sometimes, by great violence, the scapula it-
self is driven downwards, and the acromial  end  of  the clavicle then
projects upwards.   Sir Astley Cooper, in his work on dislocations,
gives us a drawing of such a case.  Here the ligaments,  tying the
clavicle and acromion together, are torn, as well  as  some of the
bands of ligaments connecting the clavicle with  the coracoid pro-
cess.  The treatment consists in keeping the shoulder inclined out-
wards, by placing a wedge shaped cushion below the  axilla, and in
using the figure-of-8 bandage, with a soft pad in  each  axilla, to pre-
vent its margins from  being chafed.   When, by  this means, the
shoulders are drawn back, the acromion returns  into its place. The
arm is of course to be kept up with a sling.
  My friend,  Mr.  Morton,  of University College,  has favored me
with the particulars of an  unusual dislocation of  the sternal extrem-
ity  of the  clavicle;  the  displacement  of  it being   upwards and
inwards.
  Etienne Cardron, set. 39, mason, admitted into the Hospital of La
Charite on account of an  injury,  which was caused by his having
been violently squeezed between  a wall and  a cart, in  such  a  man-
ner that the left shoulder was thurst inwards with great force.   On
examination, the sternal extremity of  the  left clavicle  was found to
have been displaced from  its natural situation,  and  was now placed
above the upper edge of the sternum,   producing a  slight  deformity
in the contour of the lower  part of the front of the neck.  It seem-
ed, from the description of the accident which was  given by the pa-
tient, that the  force producing the injury had acted  in such a direc-
tion as to push the sternal extremity of the dislocated bone upwards,
and behind the sternal portion of  the sterno-cleido-mastoid muscle.
The articulating surface of the internal extremity of the dislocated
clavicle lay opposite to that of the clavicle  of the  sound  side, and
was supported  by the superior  border of the  sternum.  The at-
tachment of the sterno-cleido-mastoid muscle to the  first bone of
the sternum did not appear to  have suffered any  laceration.   M.
Velpeau considered it to be very probable,  that  the dislocation was
in the first place backwards, but  that  the  force  continuing to act,
the  end of  the  clavicle was  afterwards driven .upwards, and across
the  front of the root of the neck, and behind the storno-cleido-mas-
toid muscle.   The dislocation was reduced in  the usual manner,
and the apparatus of  Default for fractured clavicle  employed to re-
tain the end of the bone in its proper  place.  The bandages  used
                       31* 
366              PARTICULAR  DISLOCATIONS,
Were steeped in a solution of " dextrine,"  which, when dry, ren-
dered the whole immoveable.
  Sept. 6. The apparatus has been reapplied, as tbe extremity of
the  clavicle had again become slightly displaced in the same  direc-
tion as before.
  Sept.  15.  Doing very well.

     DISLOCATIONS  OF THE  HUMERUS AT THE SHOULDER

Are so common,  that it has been rather incorrectly supposed, that
they equal in number all other dislocations put together; and when
various circumstances relating to the shoulder joint  are considered,
we  must discern several' which account for the frequency of these
accidents.  First, the glenoid cavity is very shallow and  small in
proportion to  the  size of the  head  of the  humerus, which, in the
perpendicular direction is twice as  broad as  the articular cavity, and
in the  transverse direction, not less than three times as wide.   Sec-
ondly, this joint  derives no  material  strength from ligaments, the
capsular  ligament being  particularly weak  and thin  below, where
there is nothing to resist  dislocation, and  thick  above, where the
acromion, coracoid process, and triangular  ligament, form insur-
mountable obstacles to such an accident.   Thirdly,  we are to re-
member, that the shoulder joint  is  capable of motion in every direc-
tion, and the muscles surrounding it and attached  to the humerus are
numerous, the consequence of which disposition is, that the head of
the bone must in many positions make considerable  pressure against 
    DISLOCATIONS  OF  THE  HUMERUS AT  THE SHOULDER.  367

the capsule.   Dislocations of the humerus would, indeed, be more
frequent than they are, if the scapula were more fixed; but as this
bone is as moveable  as the humerus itself, the  glenoid  cavity ac-
companies all  tbe movements of the head of the latter bone, and
thus forms a very accommodating support to it.
   The head of the humerus is subject to three complete dislocations,
and one of an incomplete kind.   The most  common  of  the  three
complete dislocations takes place downwards into the axilla, the head
of the  bone pressing against the inferior costa of the  scapula, and
passing into that situation between the  long portion of the triceps,
and the tendon of the subscapulars, which is sometimes lacerated.
In the next most frequent case, the  head of  the humerus  is thrown
under  the  pectoralis major and  pectoralis  minor muscles, on the
sternal side of the coracoid process, so as to lie below the middle
of the  clavicle.   As the pectoralis minor is attached to the coracoid
process,  the head of the bone must pass under that muscle in order
to reach the situation which has been  specified.   This fact,  I be-
lieve,  is not demonstrated in any preparations in London;  but Sir
 Astley Cooper refers to a specimen, from the appearance of which,
it was  inferred that  the  head of the humerus had certainly passed
under  the pectoralis minor, as well  as the pectoralis  major.  The
third complete dislocation is  backwards, on the  dorsum of the sca-
pula,  under the spine of that bone;  but this is so rare an accident,
that Baron Boyer, in the whole course of  his  experience, never
met with more than two examples of it, one of which  was accident-
ally noticed in the dead subject.  Sir Astley Cooper, also, during
an experience of more  than forty years, has met with but  few in-
stances of it.   One  such case was brought to University  Hospital,
and reduced by  Mr. Morton, late house-surgeon.
   In the incomplete  dislocation, the  head  of  the humerus is thrown
forwards  on  the external side  of the  coracoid  process, and the
capsular  ligament is  lacerated;  but the bone  does  not entirely
quit it.
   What are the symptoms of a dislocation of the head of the hu-
merus into the arm-pit?   Three symptoms are common to  all dislo-
cations of  the shoulder:  first, loss of the rotundity of the  shoulder;
secondly, a hollow under the acromion;  thirdly, the acromion forms,
or seems to form, a greater projection than natural.   In addition to
these symptoms, when  the head  of the humerus is lodged in the
axilla, there will be a lengthening of the arm; if we look at the pa-
tient from  behind, the elbow of the  affected limb will plainly seem
to be lower than the elbow of the other arm; it will also be inclined
a good way from the trunk, and the  patient  cannot  put it close to
his side.    This latter circumstance is one of the first  things about
which I usually make inquiry, when  called to a  supposed disloca-
tion of the shoulder; and if the patient  can put his arm close to his
side, I then know that there cannot  be  a dislocation into the axilla. 
368
PARTICULAR DISLOCATIONS.
In such a dislocation, he is also unable to raise his arm to  a level
with the acromion.   In consequence of the limb being lengthened,
and the humerus carried downwards, the deltoid is necessarily flat-
tened, and this, not merely  on account  of the  bone  quitting  its
place, but from the fibres of the muscles being put on the stretch.
It is,  indeed, in consequence of this, that the arm is  held out from
the side.  The long  portion of the triceps is also stretched; and
one effect of this is, that the fore-arm  is always found more or less
extended, while the stretched  condition of the head  of the biceps
accounts for the head being thrown into the  state of supination.  If
the arm be raised from the side, we may distinctly feel  the head of
the humerus in the axilla.   In addition to the above symptoms, the
functions of the joint are suspended, and, instead of free motion of
the arm, there is  an extraordinary rigidity of it.   The manner, in
which the accident commonly happens, is  this;—the patient falls
while his  arm is  raised from his  side, or, I should rather say, he
endeavors to save himself from  injury by holding out  his arm; the
arm comes to the ground in this  position,  and the  resistance of the
ground  suddenly throws the lower portion of the humerus upwards,
and propels  its head downwards, which latter movement is at the
moment also promoted  by the spasmodic  and violent action of the
pectoralis major and latissimus dorsi muscles.   Thus, supposing the
arm to be raised  from the side at  the  time  of  the fall,  without too
much inclination  either backwards or forwards, the dislocation will
be into the axilla.
   In  another  dislocation, which  is tolerably  frequent, where the
head of the humerus is thrown under the pectoral muscles, and on the
inner side of the  coracoid process, the  head of the  bone  can  be
felt in its new situation; the axis of the  bone  is also  directed to-
wards this point;  not towards the  glenoid cavity, but the centre of
the clavicle.   The elbow is seen to incline  more or less backward.
The head of the humerus being more wedged in  its new situation
at the inner side of the coracoid process, than when it lies in the
axilla, the limb is still more rigid, and  there is  less  possibility of
moving it.  The limb is also shortened; whereas, in the  luxation
downwards, it is  lengthened.   In addition  to  these,  there will of
course be the three common symptoms, namely, a hollow under the
acromion, a considerable  projection of that process,  and a diminu-
tion of the rotundity of the  shoulder.
   The dislocation forwards,  under the pectoral muscles and centre
of the clavicle, takes place in the  following  manner: while the arm
is inclined somewhat  backwards, and  separated from  the side, the
person falls with great force  on his elbow, or lower end of the hume-
rus, the head of which is consequently forced upwards and forwards.
It does not  always pass immediately underneath  the  clavicle, but
undergoes that secondary species  of displacement, to which I in-
vited attention in the genera)  observations  on dislocations: it is 
    DISLOCATIONS OF  THE  HUMERUS  AT THE SHOULDER.  369

first thrown  under the pectoral muscles,  and then the action of the
muscles draws it higher and higher, till it is brought close under the
centre of the clavicle at the inner side of the coracoid process.
   A dislocation backwards can  scarcely happen, except  when the
arm is inclined  forwards, across the front of the  chest, and  it is
difficult to imagine how  any force can act so as to dislocate the bone,
even when the arm is in this  position; for  any violence, at all like-
ly to be applied,  would generally propel the  arm against the chest,
and this, no doubt, is the reason why the  dislocation backwards is
uncommon.  As the head of the bone is always conspicuous below
the spine of the scapula, the diagnosis  is not liable to any mistake.
In this case, the elbow is not separated from the side, as it is in the
more common dislocation  into the axilla.
   What is the mischief produced when the head of the humerus  is
dislocated downwards into the axilla ? There is sometimes a lasce-
ration of the tendon of  the  subscapularis;  the  tendon of the  long
head of the biceps is also stated  to be sometimes broken or displac-
ed ;  but so far as the dissections of Sir  Astley  Cooper and  Boyer
go, it appears that  neither of these circumstances has fallen under
their notice.   One instance,  however,  is  recorded by  Mr. Hey,
 where,  in a compound dislocation of the  shoulder, an extremely rare
case, the head  of the humerus  protruded through the  integuments,
and the tendon of the biceps was really torn.   Of course, the  cap-
sular ligament is lacerated,  and there  may be a laceration of other
tendons and muscles.
   Every plan for reducing dislocations of the shoulder ought  to com-
 bine three principles; viz. extension, counter-extension, and  the em-
ployment of the shaft of the bone as a lever for moving  its head in-
to the glenoid cavity; and also  a fourth  principle, which is  the re-
laxation of the muscles, so far  as  this may be practicable,  without
neglecting the other indications.  The  manner of making counter-
extension  is by means of a girth or sheet,  applied round the chest,
and either held by  the assistants, or fixed  to some point  in  the di-
rection  opposite that in which  we purpose to make extension.   A
piece of strong linen, with an aperture or slit in  it, for the reception
of the arm, will serve  very  conveniently both to fix the chest, and
hold back the scapula.  Whatever means  be exployed for  keeping
back the shoulder,  the pressure  is not to be applied to the  glenoid
cavity,  or too near the acromion; for then it would form an obsta-
cle to the return of tbe bone  into its proper situation.
   With regard to the manner of making the extension, and  the di-
rection  in which such extension ought to be made, I may observe,
that French surgeons would generally make extension as far as  pos-
sible from the joint concerned:  thus,  in  a  dislocation of  the shoul-
der, they  would make  it at the wrist: but,  in this country,  the ex-
tending means are most commonly applied  to the lower part of the
humerus itself; and the reason for this is, that British surgeons fre- 
370
PARTICULAR DISLOCATIONS.
quently prefer keeping the fore-arm bent, by which means the  bi-
ceps is relaxed.   They consider that, as the portion of this muscle
attached to the coracoid  process must be  stretched when the arm
is extended, it would in this state tend to  hinder  the shoulder from
being kept properly back;  and, on this account, they keep the fore-
arm  bent, and apply the extension to the  lower part  of the  hume-
rus.   In the plan used in France, there is the advantage of a long
lever,  which,  perhaps, fully counterbalances the  good derived in
our method  from  the relaxation of  the biceps.   Before  applying
the napkin, or cloth,  for the purpose of making extension, it  is cus-
tomary to place something immediately round the  limb, in order to
prevent the skin from being chafed  or  too much  irritated; and in
this country, it  is usual to apply a  piece of wet  linen, or  a  few
turns of a flannel roller, for the purpose.   We then  take a piece
of strong calico, or linen, which must be three yards  long, and
half a yard wide, and fold  it longitudinally, till it  forms a  long ex-
tending means, about three inches in width.  An  ingenious way of
applying this is mentioned by the late Mr.  Hey, which is rather dif-
ficult to describe, though very simple to show: he places the noose
first  in an elliptical form round the limb; he next  takes one  of  the
ends and passes it over to the opposite side through the noose; then
he does the same with the other end; and  the more this  apparatus
is  pulled, the  tighter it becomes.   The contrivance is simple  and
effectual.  Another contrivance is what  the sailors call the clove-
hitcli knot, a drawing of which may  be seen in Sir Astley Cooper's
book.   With  the cloth, three yards in length, there is, when it is
applied,  more than a  yard left for  the assistants to make  extension
with.  When the dislocation is downwards into the axilla, the ex-
tension ma)r first be made in the direction  of tbe axis  of the bone,
that  is, downwards and outwards, in  order to dislodge its head from
the inferior costa of the scapula.   When  sufficient extension in this
direction has been made,  the next object  is to have recourse to the
lever-like movement of the shaft of  the bone, and for  this purpose,
many surgeons place  one knee in  the axilla, and  make a fulcrum of
it, and as soon as they see, that the  head of the bone  has been by
these  means  brought towards the  glenoid  cavity, the  extending
power is relaxed, and the muscles draw it  into its place.   On such
principles, the reduction is, in general, easily effected.  If the  pa-
tient be intoxicated, then we are to take advantage of this condition,
in  which a dislocation may aften  be  reduced without performing
any extension  at all;  indeed, when  the person is  faint, or intoxicat-
ed, if we place the bone over the  back of a chair, or over our knee,
the dislocation may often be reduced with little or no extension.   I
have seen this frequently  done on drunken persons; and sometimes
the bone will slip into its place on the patient moving the arm him-
self, while it  is  suspended  over the back  of  a chair, or the mere
weight-of the  limb will be sufficient to effect the reduction.   An 
    DISLOCATIONS  OF  THE  HUMERUS  AT THE  SHOULDER.  371

old and not a bad method of reducing a dislocation  in the axilla is
that, in which the surgeon places his heel in the arm-pit, and makes
extension from the hand or wrist.  The heel not only fixes the chest,
and keeps back the  shoulder, but  constitutes a fulcrum on which,
by the lever-like motion of the limb, the head  of  the humerus can
be directed into the glenoid cavity.  It would appear that, in some
cases, the connection of the supra-spinatus muscle with the greater
tubercle, is the cause of the resistance to  the  extending  power.*
Here the resistance is most  effectually  overcome  by  raising the
arm, and relaxing the supra-spinatus.   On  this subject, Sir  Philip
Crampton justly remarks,  "The success, which  not unfrequently
attends the method  of reduction (first recommended by Mr. White,
of Manchester) by drawing the arm directly upwards, in a line  par-
allel to the axis of  the trunk, is, no doubt, to  be  attributed chiefly
to the relaxation, which it effects, of the supra-spinatus and deltoid
muscles.  It is probable also, that, in  this position of the humerus,
the head  of the bone is in  some measure unlocked from  the  neck
of the scapula,  against which  it  is (when  dislocated downwards)
strongly compressed by the contraction of the muscles."  Mr. Hey
particularly recommended White's method for old  dislocations.   In
1785, a memoir in favor of the  same practice was addressed to the
Academy of Surgery,  by M.  Mothe.   The  consideration  of the
anatomy  and  pathology  of the dislocation  into the axilla  led Mal-
gaigne, one of Dupuytren's pupils, to be an advocate  for the me-
thod, which gained  also the approbation  of the latter distinguished
surgeon.   White first described this mode of reduction in a paper,
printed in 1764.f
  When the  dislocation is forwards, under the centre of  the clavi-
cle,  the elbow is inclined backwards  and  downwards,  and,  if we
were  to attempt to bring the head  of the bone  direct from  its situa-
tion, below the clavicle, into the  glenoid cavity,  we might fracture
the coracoid process.  This shows the necessity of attending to the
principle of first dislodging the bone from the situation in which it has
been thrown  by the secondary displacement.  In this  dislocation,
the bone is first thrown out of the glenoid cavity under the pectoral
muscles, but  does not mount up to its situation under the centre of
the clavicle till the secondary displacement  takes place.   This dis-
placement must first  be obviated  by  pulling the bone  downwards
and backwards in the direction  assumed by its axis, as one of the
effects of the accident.   Now, as soon as the head of the bone has
been brought below the  coracoid process, we  are  to incline the el-
bow more forwards, and  bring it closer to the side;  thus  we shall
direct the bead of the bone towards the glenoid cavity; at the same
  • Sir Astley Cooper on Dislocations, p. 377.
  t See Compton's Obs. in Dublin Journ. of Med. and Chemical Science, vol. iii. p.
181. 
372
PARTICULAR DISLOCATIONS.
time we may use a band or napkin,  placed under the upper part of
the humerus, as a fulcrum; for, in this case, we cannot well get our
knee under the axilla, so as to make a fulcrum of it.
   It has sometimes been suspected, that all dislocations of the shoul-
der are first downwards; but  a  dissection, the particulars of which
are given by Sir Philip  Crampton, proves, that this is not the case,
for the bone was thrown under the pectoral muscle, without the low-
er portion of the capsular ligament  being at  all torn.
   The other  less common dislocation, where the head  of the hu-
merus  is thrown  upon the dorsum of the scapula, is believed by Sir
Astley Cooper to differ from  other  luxations of the shoulder in be-
ing the result of muscular action alone.   He  has recorded one case,
in which the displacement of  the head of the humerus was produced
by the convulsive  action  of  the muscles in  an epileptic fit.   I re-
member one case,  however,  in  which this  dislocation arose from a
violent blow on  the front of the shoulder.    In the example lately
recorded by  Sir Astley Cooper, it  was found, on dissection, that
the tendon of  the subscupularis and  the capsular ligament had  been
torn from the smaller tubercle  of the humerus, and  the bone was
consequently drawn back by the action of the infra-spinatus and teres
minor.  Hence, there was no support given to the head of the bone,
when reduced, and, consequently, a return of the displacement en-
sued.  This,  however,  is an  exception to what has usually  happen-
ed; for, after the bone has been reduced, the reduction has common-
ly been permanent.
   This dislocation is peculiar in not being attended with any eleva-
tion of the elbow from the side.  The  reduction may generally be
accomplished  by fixing  the shoulder, making  extension, and then
pushing the head of the humerus forwards towards the glenoid cav-
ity.   In one case,  Sir Astley Cooper bent the elbow at a right an-
gle, and raising the arm, carried it behind the patient's head,  so as
to bring the hand across the back of the neck to the opposite shoul-
der.   Then forcing the elbow  back, and pressing upon the head of
the bone, he pushed it under the inferior costa of the scapula, and
it  instantly returned  into the  glenoid cavity.  This dislocation has
also been reduced with  the heel in the axilla, and  extension made in
the direction of  the trunk.*
   Thus the reduction of dislocations of the humerus is performed on
the combined  principles of extension, counter-extension, relaxation
of the biceps,  and the lever-like  movement of the shaft of the
bone.  I might add to these the very important principle of dislodg-
ing the head of the humerus  from the situation  in  which it has been
thrown by the  secondary displacement.   When difficulty in effecting
the reduction  is experienced,  we can have  recourse  to debilitating
• See Guy's Hospital Reports, vol. iv. p. 265. 
     DISLOCATIONS OF THE  HUMERUS AT THE SHOULDER.  373

means, such as copious bleeding frcm a large orifice in the vein, or
the administration of tartarised antimony, with the view of bringing
on that collapse of the muscular system, which  naturally accompa-
nies faintings and  nausea.  Then, so far as  the muscles are con-
cerned, the difficulty of reduction is removed, and the head of the
bone, if the case be not an old dislocation,  may  be readily put into
its right place  again.   Sometimes,  in examples of difficulty,  the
multiplying pulley is used.  After  the reduction, the  next indica-
tion is, to prevent the bone from slipping out  of  the  glenoid cavity
again.   For  this  purpose a  sling  is  generally sufficient; but,  for
greater security, if the patient be tipsy and restless, we should con-
fine the humerus to the side with a roller.
   It is mostly allowed, that the humerus may be incompletely dis-
located, and  remain fixed on  the outside of the coracoid process,
the front of  the capsular ligament  being torn, but the head  of  the
bone not  being thrown out of it.  The reality  of the accident is
sometimes disputed.   I have  not seen any decided example of it in
my own practice;  but Sir Astley  Cooper's  observations leave, I
think, no doubt about its possibility; and in his work  is a plate, rep-
resenting the slate of the parts, as found on dissecting  the shoulder
after such an accident.   Should  it be met with, the reduction ought
to be effected on the same principles  as are observed when the head
of the bone is  thrown to the   inner side  of  that  process; and after
tbe reduction, a compress is  to be applied in front  of the head of
the humerus, just  on the outside of the coracoid  process, supported
by the spica bandage.  In one instance, recorded  by Mr. South,
the coracoid process was broken.*
   [There is another form  of luxation  at the  humero-brachial  articu-
 lation, which I  do not recollect to have seen mentb ned by any author,
 and which came under my observation  iti July, 1836-   The  head of
 the brachian was thrown under the scapula.  Tbe patient was a young
 man, aged twenty-two, an operative  in  a woollen mill.  While he
 was  attempting to  shift the position of a belt, bis hand  was caught be-
 tween tbe belt and tbe drum, and carried round, strongly pronating it,
 and, as it were, twisting  the bone from its socket.
   The head of the hone could he felt under ihe scapula, and the  arm
 and fore-arm lay obliquely across the chest, with the back of tbe hand
 turned towards the body,  and the palm looking outward.  Tbe rotun-
 dity of the shoulder  was gone.
   To reduce this luxation, tbe arm and fore-arm were  brought down
 to the side of the  body, and tbe limb twisted into its naturalposiiion;
 in consequence of which  the  head of the bone wad brought  into the
axi 11 «i; from which position it was restored in the ordinary way to the
 glenoid cavity.—En.]
                 * See Med. Chir. Trans, vol. xx\\.
vol.  ii.                 32 
S74
PARTICULAR DISLOCATIONS.
                 DISLOCATIONS OF  THE  ELBOW.

   The displacement of both bones of the fore-arm forwards cannot
 take place without a  fracture of the olecranon, which process of the
 ulna forms a mechanical impediment to  such an accident; indeed,
 it is an accident  of  great rarity.  In  the Museum of University
 College is a preparation, in which the olecranon was fractured, and
 also the coronoid  process; and the radius and ulna were dislocated,
 but not both of them forwards, for the ulna was thrown backwards.
   A boy, in attempting to leap over a post near  my house, fell
 down  and dislocated  his elbow; it  was a  dislocation  of the  ulna
 backwards and  of the radius forwards.  I had not the slightest diffi-
 culty in reducing the case, which terminated favorably.   The most
 common dislocation of the elbow, is that, in  which  both bones are
 thrown backwards, either with  or without a fracture of the coronoid
 process.
   When the coronoid process is not fractured,  it passes into  the
 fossa at the back of the humerus, in which the olecranon  is natural-
 ly situated.  On this account the arm cannot  be completely extend-
 ed; the olecranon forms a remarkable projection  behind  the arm;
 and the distance between the point of the olecranon and the internal
 condyle is conspicuously increased;  the humerus itself also forms a
 projection in front of the upper part of the bones  of the fore-arm;
 and the radius is thrown on the outside of,  and  above, the external
 condyle.   It is of great use,  in these dislocations, to attend  pre-
 cisely  to the relative  positions of the point of the  olecranon,  and
 the external and internal condyles;  for, sometimes  the swelling is so
 great as to prevent us from making out the  case satisfactorily, unless
 we avail ourselves of these beacons.   In the  dislocation of the  ulna
 backwards, the  distance between the olecranon and the internal con-
 dyle is remarkably increased;  these points may always  be felt in
 the fattest persons, and however great the swelling.
   In the dislocation of the ulna backwards, there is a laceration of
 the capsular ligament, and of the internal lateral ligament, and gen-
 erally, also, of the annular ligament of the radius, which is closely
 connected to the external lateral ligament.  In consequence of  the
 lower head of the humerus being thrust forwards, the brachialis an-
 ticus is liable to be torn;  but the tendon of the biceps generally es-
 capes, and is tightly applied round the lower articular surface of the
 humerus.   However, if the dislocation has been caused  by exces-
 sive violence,  that tendon may be torn,  and even other mischief
 done;  for example, the brachial artery may be ruptured, the median
nerve torn, and the veins at the bend of the elbow  burst.  In the
ninth number of Cruveilhier's great work on Pathological Anatomy,
some notice is taken of a case,  where such complications occurred
in a lady, who fell from her horse with prodigious force. 
DISLOCATIONS  OF  THE  ELBOW.
375
  The mode of reducing this dislocation is simple:—The surgeon
may apply his knee to the bend of the arm, and, taking hold of the
wrist, bend the elbow over his  knee with the  advantage  of a con-
siderable lever;  the coronoid process will then quit the fossa at the
back of the humerus intended for the olecranon, and,  by continuing
the movement of flexion a little further, he will find the bone return
into its right situation.   Now, if the coronary or annular ligament
of the radius be torn, this bone will slip out of its place again,  un-
less means be taken to prevent it.   With this  view, we should  ap-
ply a compress over the head  of the radius,  to  press it  down to-
wards the lesser sigmoid cavity of the ulna; and we should prevent
the radius from moving  by means  of splints,  one on the  outside,
and another on the  inside of the  fore-arm.  If a case of this  de-
scription were to remain unreduced, which sometimes happens, na-
ture makes great efforts  to repair  the mischief; and it is to be ob-
served,  that the dislocation is complete, the articular surfaces  not
being at all in  contact with each other.   Sometimes, indeed, a sur-
prising attempt is made  to form a new socket for the humerus.   In
the plates of  Cruveilhier's celebrated work, a representation of such
a dislocation, and of the efforts made by nature to repair  the mis-
chief, is  given;  a considerable quantity  of bony matter  has been
thrown out to  form a socket for the humerus.   These plates also
show the changes which take place in the shape of the bones, when
their functions have been destroyed by  remaining long unreduced.
In the instance here exhibited,  a very limited degree  of motion re-
mained; and nature had done all in her power to produce a new ar-
ticular cavity.
   Sometimes  the dislocation takes  place  in another way, the ulna
being thrown backwards, and the radius forwards; the former bone
assuming the  position  described  in the last dislocation.   The case
is reduced nearly in the  same way  as the  foregoing; but we are to
make some extension, for otherwise we could  not bend the elbow
with the radius in front of the humerus; and after the requisite de-
gree of  extension has been made,  the bones will return to their pro-
per situations on bending the elbow over  the knee.
   Tn other instances,  we find a dislocation of the radius alone;  the
upper head of which bone quits the lesser sigmoid cavity of the ul-
na, and  is thrown on the outside of the external condyle, and some-
times behind it.  The nature of the accident is sufficiently obvious;
for the head of the radius is thrown on the  outer part of the arm.
I have seen three or four examples of this case, and there are many
instances of it on record.   There  is an engraving of one such case,
which was dissected by  Cruveilhier; the  dislocation had  not been
reduced, and nature had formed a  sort of fibrous capsule for the re-
ception of the head of the radius,  which  capsule Cruveilhier thinks
was derived either from  the  remains  of the annular or of the exter-
nal lateral ligament.   The same plate also illustrates the  change, 
376
PARTICULAR DISLOCATIONS.
which takes place in the articular surface of a  bone that  has been
long out of its  place.   For the reduction of  this dislocation,  the
best plan is to make extension of the arm, and to limit the exten-
sion as much as possible to the radius;  thus we can draw the dis-
placed bone into its proper situation.  Now, the head  of  the radius
will be apt to  slip out of its  place again, unless means be taken to
prevent it; we must, therefore, hinder all motion of the radius with
splints, and  support the head of it with a compress.   This tenden-
cy  of the head of the  radius to quit the lesser sigmoid cavity after
the reduction, is owing to the annular and  oblique ligaments  being
torn.   A child was once brought to me at the Bloomsbury Dispen-
sary, with this dislocation; the accident had occurred seven weeks
before I saw the case, and nothing would avail in  keeping the head
of  the radius in  its place: we applied splints for three or four weeks,
but at the end of this time, the bone glided into, and out  of, the ar-
ticular cavity  as readily as ever.
   The most common lateral dislocation is where  the ulna is forced
outwards into  the place of the radius, which is propelled  off the ar-
ticular surface of the  humerus altogether.    In  this state of  tbe
bones, there is no suitable cavity behind the humerus for  tbe recep-
tion of the  olecranon  in the extended  condition of the  fore-arm.
The consequence  is,  that complete extension cannot take  place:
neither can  flexion  be well performed.  The  case is  sufficiently
manifest from the extraordinary projection formed by the inner con-
dyle on  one side, and  by the radius on the other.  Extension  and
counter-extension are to be made, and  the ulna and radius reduced
by lateral pressure.
   Dislocation of the lower end of the ulna jrom the sigmoid cavity
of  the radius  takes place mostly  from a forcible  pronation of the
hand, the ulna being then  thrown back, and the  hand fixed  in the
position of pronation.   There is a possibility,  however, of  the  dis-
placement occurring in  the  other  direction, or of the   ulna being
thrown forwards  and  the hand  supine.   Here  extension is to be
made, and  the  displaced bone pressed in the direction required to
bring it into the proper position again: then a splint is to  be applied
to prevent the radius from moving.

                 DISLOCATIONS OF THE  WRIST.

   A gentleman  once asked me if it were true that the wrist was nev-
er  dislocated?  To which I answered,  that it was not possible for
me to agree in that doctrine, because I had seen a case, in  which
the lower end of the ulna protruded through the  skin.   However,
his question related to the possibility of a dislocation of the radio-
carpal articulation,  Various anatomical  reasons are assigned by
Dupuytren, why the  radius  should always rather  break,  than be
dislocated from  the carpus; and  he distinctly declares it as his be- 
DISLOCATIONS OF  THE WRIST.             377
lief, that there is not, in all  the records of surgery, an unequivocal
specimen of such a dislocation.   He had  sometimes been called to
cases, supposed at first to be true dislocations of the wrist, but
which afterwards proved to be only fractures of  the  radious near
that articulation.  One or two instances of such mistakes, verified
by dissection, are brought forward, in  which  practitioners of emi-
nence had been deceived.  Hence the Baron is led to conclude,
that a dislocation of the wrist is scarcely a possible event,  and that
the accidents, reputed  to be such, were in  reality fractures of the
radius close to the joint, with more or less  displacement of the hand.
It cannot  be  doubted,  I think, that this  is generally the fact: but
it would be making a bold  assertion to say, that such  a dislocation
never happens.   Great as  Dupuytren's experience  is, it is merely
a drop in that  great ocean of experience, to  the  rich treasures of
which the  surgeons of every age  have  successively  contributed.
Instead of representing  a dislocation of the radius from the carpus
as impossible, it would,  I  believe, be more correct  to say, that
the accident is  exceedingly rare.   In  Sir Astley Cooper's  work,
'there is a drawing of a  dislocation of the carpus backwards, which,
no doubt, is  particularly uncommon;  for when a person falls on
his hand while it is extended, the  force would  almost always sooner
break the radius than dislocate it  towards  the  palm;  but if the hand
were in the state of flexion, so  that the back  of the hand received
 the force, then  a dislocation might perhaps  be a more likely  event.
Cruveilhier had an opportunity of dissecting such a dislocation, as
he believed it to be, in which the radius and  ulna  had  been thrown
on the back of the hand, and the state  of the parts is represented in
 one of his plates;  the patient, he conceives, had fallen on the back
of the hand with considerable force.   Yet Dupuytren  and Cruveil-
hier took different views of this preparation, so that further investi-
gations are desirable.   In Cruveilhier's book,  we also find  an en-
graving  from a case,  in which the radius  had been dislocated by
the contraction of a burn.   Sir Astley Cooper also speaks of a boy,
 who  fell  on the palm of his hand, and whose  carpus was  driven
backwards.   I  am not therefore disposed to consider  Dupuytren's
doctrine as completely established; in  fact,  it  is difficult to restrict
the effects of the external violence on the joints, considering  the in-
finite variety  of circumstances  by which  they may  be  modified
and influenced.
   [During Sept. 1844,  T was called to see a boy aged  twelve,  who
 had just fallen and  injured his wrist.  Dr  F. U. Johnston and  myself
examined the  case, and found it to  be a well marked case of luxation
 backward, so  as to rest upon the lower part of the radius.  It was  a
clear ease'of  luxation  uncomplicated by fracture, and  certainly dis-
proving tbe dogma of Dupuytren. —Ed.]
   If we were to meet  with a dislocation  of the radio-carpal  artic-
ulation, it  would  be easy of  reduction,  as  dislocations of gingly-
                      32- 
378
PARTICULAR DISLOCATIONS.
  moid joints usually are;  the extension and  counter-extension need
  only  be  made  in a  degree sufficient  to   diminish  the  friction
  between  the  articulating  surfaces,  and then  pressure is to be
  made on the displaced bones in the  direction calculated  to  bring
  them into their right situation again.   Extension and counter-exten-
  sion would be necessary, if the dislocation  of the carpus were for-
  wards, and splints would be required;  for otherwise the movements
  of the hand  might bring on a return of the dislocation, and  prevent
  the speedy union of the ligaments.

  DISLOCATIONS  OF THE  BONES  OF THE  CARPUS  FROM  ONE
                             ANOTHER.

     The bones  of the  carpus are not very liable to be  dislocated
  from one  another: however, there is one in  the second phalanx,
  which is  occasionally thrown  out of its place,—I mean  the  os
i  magnum.   This bone is received into a deep cavity formed by the
  scaphoid and lunar bones, and  when the  hand is violently  bent, it
  will sometimes start out of this cavity, and forma considerable pro-
  jection at the back of the  wrist.   The reduction  is  occasionally
  difficult; but,  if the bone be left unreduced, there will  not be much
  inconvenience,—there will  only  be  a  slight weakness  of  the
  wrist.   Thus, in one  insiance, which  was attended by Sir Astley
  Cooper, the inconvenience,  resulting from the non-reduction of the
  dislocation,  was, that  the young lady, who  was the subject of it,
  could not  practise music—she  could not play on  the piano-forte.
  The case will  be evident  from the situation  of the bone,  and  its
  projection beyond the other hones  of the carpus.   The accident
  chiefly occurs  in children ana females, from  the greater weakness of
  their ligaments, and also from the cavity of the scaphoid and lunar
  bones being more shallow in them than in male adults.  In reducing
  this dislocation, we are to bring the hand into the extended position,
  and  then  press  firmly on  the  projecting bone with our  thumbs.
  The common  plan of palliating this dislocation, when it  cannot  be
  reduced, is to apply a  compress and  bandage over it, or straps of
  adhesive plaster.
    The metacarpal bones  can hardly be separated from one  another
  except by great  and  direct  violence; and so  closely are  they tied
  together  and  to the carpus, that scarcely any thing,  except  gun-
  shot violence, the bursting of a fowling-piece, or pistol,  or the fall
  of some ponderous body on the hand, can dislocate them.  However,
  the  metacarpal bone  of  the thumb  is more  frequently dislocated
  than any other; and, from its having motion in  every  direction, it
  seems  capable of being  dislocated in four  directions,  namely, in-
  wards, outwards, forwards, or backwards; but experience  proves,
  that  it is ordinarily dislocated only forwards or backwards.  When
  a person falls on the radial edge of his hand, and the thumb  is car- 
DISLOCATIONS  OF THE THUMB.
379
ried  violently  inwards, the head  of the  metacarpal bone  will  be
thrown on the back of the trapezium.   In other instances,  the dis-
placement is in the opposite direction, and  the  head of the meta-
carpal bone of the thumb  is then thrown  between  the  metacarpal
bone of the fore-finger and the inside of the trapezium.   The reduc-
tion is easy: the principle is to make counter-extension from the wrist,
and extension from the thumb, and to press the bone in the proper
direction.

                DISLOCATIONS OF  THE  THUMB

Are sometimes  difficult to reduce, especially those  of the first pha-
lanx from the metacarpal  bone.  There are some persons, howev-
er, who have the ligaments of this joint so  loose,  that at their option
they cannot only  dislocate the first phalanx by the action of the
flexor muscles, but even  replace it  again by the action of the ex-
tensors.  In such  instances of spontaneous  dislocation  and reduc-
tion, the ligaments are preternaturally loose.  Sometimes this  may
be  the result of  the disease, or the neglect of a  dislocation, where
the bone had been reduced, but not well supported  in its place.
   In the  common dislocation of the  thumb, the head of  the first
phalanx is thrown  on the back of the head of the metacarpal bone,
so that the first phalanx projects backward,  while the  head  of the me-
tacarpal  bone  inclines  towards  the  palm,  the   thumb  remains
without the possibility of being straightened, and tbe  second  phalanx
is fixed in the bent position.   It is from there being no laceration
of the lateral  ligaments that the reduction is so difficult;  for the
wedge-shaped head of the first phalanx  glides with  its narrow  part
through the aperture between the lateral ligaments,  and  brings the
broad part within them.   Thus, the first phalanx is  completely and
firmly wedged between the lateral ligaments,  which must therefore
be considered as forming the principal impediment to the reduction.
The muscles of the part also being strong, form  some resistance to
the reduction, especially as the surface for the application of the ex-
tending means is very limited.  From these various  causes, there is
occasionally so much  difficulty in the reduction, that, in  a  case  in
St. George's Hospital, about fifty  years ago, extension  was made
with such force, that the thumb was pulled off.   The case is allud-
ed to by Mr. Hey, of Leeds, in his Practical Observations on  Sur-
gery.   Some time ago, a young man came  to my house with this dis-
location.   He was sent to  me by Mr.  Hughes, of Holborn, who
had tried in vain to reduce it.   Wishing Mr.  Hughes to be  present
at the reduction, I desired  him to call  upon me in the afternoon,
that we might  try our skill  together;  but, in  the  meantime,  the pa-
tient happened to meet with a relation who was a surgeon, and who
reduced it for him.  I inquired how this  gentleman  succeeded, and
was told that he fixed a piece of tape round the  thumb,  and secur- 
380
PARTICULAR DISLOCATIONS.
ed it with the clove-hitch knot, which is one in familiar use amongst
sailors; he then fastened a common street-door key to the tape, and,
of course, was thus enabled  to make extension with considerable
force,  and with success.  In fact, I had  been thinking of trying a
very similar method.   Sir Astley  Cooper, in his work on Disloca-
tions, explains his plan of reduction.  He first puts round  the thumb
a piece of soft wet leather,  to prevent the skin from being injured,
and then applies tape over it,  which he secures  by the clove-hitch
knot.    The knot proposed  by Mr. Hey would  also answer.  The
sailor's knot differs from Mr.  Hey's chiefly in there being two cir-
cles, or nooses, made instead  of one.   Sometimes  Mr.  Hey suc-
ceeded without making  any  extension at all, merely by pressing  the
head of the first phalanx towards the metacarpal bone.   Indeed, it
is easy to understand,  that if  the broad part of  the bone were con-
fined behind the lateral ligaments, the more powerful  the extension,
the greater would  be the difficulty of effecting the reduction.
  [Luxations at the metacarpo-phalangeal articulation  of the thumb,
are often extremely difficult to  reduce.  Tbe anatomy of  the parts  is
such as to render  the reduction almost impossible, when direct exten-
sion and counter-extension are  made, as  is usually advised, and as is
directed  by our  author, Sir  A. Cooper,  and  most  other  writers.
I have  seen two patienl3, within tbe last year, who had this luxation,
both  of whom came from the country, after every attempt to effect a
reduction  there had failed.   I succeeded in reducing one without any
difficulty,  but the  other  having  been  luxated sixteen days when I saw
it, tbe  case was much more  difficult, and I could not  succeed  in  re-
storing the parts, without dividing one of the lateral ligaments.
  When the phalanx is luxated  backward, the extremity of  one bone
books as it were upon the other, and the lateral ligaments are so  at-
tached, that the more force we  exert, the more  firmly they  hook and
bind.   To overcome this difficulty,  some advise  to divide the liga-
ments,  ethers to cut off"  the   head of the metacarpal bone   In order
to reduce  tbe bone, I turn it back so as  to make a right  angle with
the first metacarpus, and then  slide  the  luxated  extremity forward,
until its surface reaches  the  head of the bone, from which it. was dis-
placed, and then I suddenly flex it toward the palm of  the hand, and
the natural position is restored.—Ed.]
  Sir Astley Cooper particularly recommends the first phalanx to be
flexed  before the extension  is made.
  When the reduction  of the  first phalanx of the thumb cannot be
effected by ordinary modes, it has  been proposed  to divide one
of the  lateral ligaments  with a couching needle.   The most  expe-
rienced surgeons, however, object  to this practice,  on account  of
the frequency with which tetanus  follows  injuries of  ihe  tendinous
and ligamentous tissues  about the thumb.   Sir Astley Cooper thinks
it far more prudent even to  let the  dislocation  remain  unreduced,
than  occasion the risk of so frightful and unmanageable a disease as
traumatic  tetanus.   Other surgons recommend cutting off the head 
DISLOCATIONS OF  THE  VERTEBRAE.
381
of the metacarpal bone with a small saw, or a pair of cutting pliers,
which is perhaps better than dividing one of the ligaments.
   Sometimes the dislocation is in the other direction, and the meta-
carpal bone is at the back of the first phalanx; then there is no diffi-
culty in the reduction.
   The  second phalanx is sometimes dislocated backwards;  and, in
compound cases of this description, Sir Astley Cooper recommends
cutting  off the articular surface of the first phalanx.  After the re-
duction  of either  of  the  above-mentioned  dislocations, the joint
must be supported with  pasteboard  and  tape.   After  a fortnight,
we are  to begin to  employ passive motion.
   The   phalanges  of   the fingers are  most  frequently  dislocated
backwards;  moderate extension soon replaces them.
   Compound dislocations of the thumb frequently lead to tetanus,—
 so frequently, indeed, that some surgeons  have thought it advisable
 to amputate  in all such cases, rather than attempt reduction; but, in
 this counsel, I am not disposed  to agree; for, from the observations
 which I have delivered  on the subject  of traumatic  tetanus, it  ap-
 pears,  that amputation is a very uncertain means either  of  prevent-
 ing, or curing,  this disorder.

               DISLOCATIONS OF THE  VERTEBRA.

   The dorsal and lumbar vertebrae have such extensive articular pro-
 cesses, while their bodies are so large, their ligaments so strong and
 numerous, and  the motion between any two of them so trivial, that
 they hardly  can  be  dislocated;  and, indeed, Sir  Astley  Cooper
 states,  that  he  has never seen a dislocation of the dorsal or lumbar
 vertebras unaccompanied by a fracture of one or more of their bodies,
 or of the oblique or articular processes.   He has never seen u hap-
 pen from a simple laceration of the intervertebral substance.  Gene-
 rally, there  is a fracture of  the  articular  processes, and  of one or
 more of the bodies of the vertebra?, with dislocation of the articu-
 lar  process of  one vertebras from that of the next.   A dislocation
 from laceration of the intervertebral substance alone, may be deem-
 ed  impossible in the  lower  part of the  spine.   But, in  the upper
 part of the vertebral  column, theie may be a dislocation of the ver-
 tebras unaccompanied by a fracture, because the articular surfaces of
 the  bodies  of the cervical  vertebra  are less  extensive,  and  the
 spinous and articular processes  less  oblique.   At St.  Bartholo-
  mew's Hospital, there is a preparation in  which a portion of the
  intervertebral  substance  is lacerated,  between  the fifth and sixth
  cervical vertebras, with a partial separation  of those bones from  one-
 another, and a dislocation of the articular processes on both sides.
  There is another  instance  in  the museum  of the same hospital, of
  partial fracture of the two bodies of the lower cervical vertebra;, ac-
 companied  with dislocation of the articular processes. But the case. 
382
PARTICULAR DISLOCATIONS.
in which there was dislocation and no fracture of the articular or ob-
lique processes is sufficient to prove, that there may be dislocation of
the upper vertebras  without any  kind of fracture.   By the  favor of
a gentleman, who was attending my lectures, I was  once  enabled
to show  the Surgical Class of  University College a  specimen of
complete dislocation of the middle of the cervical vertebras, with-
out fracture.   The person,  from whom it was  taken, was killed
instantaneously by  coming in contact with the top of  a gateway, as
he was sitting on an omnibus, which was going with great speed.
   In one of the last volumes of the Medico-Chirurgical Transac-
tions, a case is recorded, in  which the body  of  one of the dorsal
vertebras was fractured, and,  at the same time, there was a disloca-
tion of one  of the articular processes of that bone from the corres-
ponding articular  process of the  first lumbar vertebra, without frac-
ture of them.
   If we  are to believe the statements of Desault, and others, dislo-
cations of the articular processes of certain portions of the spine
have occasionally been reduced.

                 DISLOCATIONS OF  THE  HEAD.

There is no case  on record, in which the os occipitis  has been sud-
denly dislocated from the atlas by external violence,  so firmly are
they connected together.  But there  may be dislocations of the os
occipitis  from the atlas in consequence of disease.  Now, this kind
of displacement generally arises from a scrofulous  caries of the joint,
or of the atlas itself.   There are also cases on  record, in which ex-
ostoses from the  occipital  bone, or from the atlas or  from the pe-
trous portion of the temporal bone, led to displacement of the atlas.
Here,  of course, the  space  for the medulla spinalis  is diminished.
yet it is not  rendered sufficiently narrow to produce  fatal consequen-
ces.   If the patient livelong enough under these  circumstances, an-
chylosis of the atlas to the os occipitis may follow,  the anchylosis
sometimes  extending to the  dentata,  and even to the  vertebras be-
low it.   There are  several specimens in the museum  of University
College,  in which this sort of  bony consolidation is illustrated.  The
symptoms of scrofulous  disease  of the upper cervical vertebras,
leading to displacement of them, were first accurately described by
Professor Rust of Vienna, and a good  account of them was subse-
quently drawn up by Mr.  Lawrence, and inserted in the Medico-
Chirurgical Transactions.   Most of the patients are young subjects.
I have witnessed  several cases within the last  three  or four years,
and they were all in young persons, two of whom  were girls.   At
the Bloomsbury  Dispensary, a  boy  was  under my  care  two or
three years  with this disease, which at length terminated in anchy-
losis.
   The symptoms are, great pain on moving the neck or turning the 
DISLOCATIONS OF  THE HEAD.              383
head;  after a time,  more or less difficulty  in swallowing  is felt;  if
pressure be made on the part, the patient experiences great agony;
the voice  is hoarse,  and there is oppression of the  breathing; but
the most characteristic symptom, when the patient is not lying down,
is, that he  is almost always found supporting his head with both hands
placed under the lower jaw,  either  because motion of the head gives
him  pain, or because the support of it gives him relief.  After some
time, the patient generally becomes afflicted with vertigo, or is at-
tacked by  convulsions, which suddenly carry him off, or he lingers
for a considerable period,  and dies hectic.   Before the fatal termi-
nation, a crepitus may sometimes be felt.
   The treatment is conducted on the same principles as that of oth-
er scrofulous  diseases of the bones and joints,  that is, if there be
pain and inflammation, we  apply  leeches, and if the  affection par-
take of a more  chronic character,  we make an  issue, or apply the
moxa, a  blister, or a  seton, to keep up a discharge  from the neigh-
boring parts, and excite counter-irritation, whereby the morbid pro-
cess in the bones may be arrested.
   Dislocations beticeen the atlas and the vertebra dentala.—The ro-
tatory  motion of the  head is performed by the  atlas moving on the
dentata, or rather by the former bone and the os occipitis revolv-
ing on the latter.  Now, when this motion is carried beyond a certain
point, a dislocation is the consequence.  Here, then, a dislocation may
be produced by external violence; and, in fact, many cases on  record
prove the possibility of such a dislocation.   If  the ligament, which
ties the processus dentatus to the edge of the foramen magnum, re-
ceive a violent twist,  by a forcible turn of the head to the right, the
left side of the dentata may be carried in front of the corresponding
articular process of the atlas, while the  right s de of the  dentata is
forced behind the  corresponding  articular  surface  of the  atlas.
When the  processus  dentatus is dislocated from the space between
the transverse ligament and  the fore-part  of the atlas, it will  p.ess
upon the medulla oblongata and spinal cord, and  produce  imme-
diate death.   In general,  there is  not a  rupture of the  transverse
ligament, but  the  processus dentatus  slips under it.  Sometimes,
however,  the dislocation of the processus dentatus backwards  is
preceded by a rupture of  the transverse ligament: but this can take
place only  in two ways,—first, from a fall with  great  force on the
occiput, as happened in a case recorded  by Boyer;  and, secondly,
from a violent fall on  the chin, as mentioned by Sir Charles  Bell.
In Children, the processus dentatus is particularly weak, and there-
fore liable to be broken;  indeed, in any subject, in whom it is more
slender than usual, it  may be broken, and then  the lower portion of
it, passing under the  transverse ligament, will make fatal pressure
on the spinal marrow.  In  consequence  of this  process not being
fully  developed in  children, and the ligaments being weaker in them
than in adults, the common trick of lifting them up by the chin and 
384
PARTICULAR DISLOCATIONS.
occiput ought to be discontinued, for it has led,  in many instances,
to a sudden displacemant of the prosessus dentatus,  and  instant
death.  A fracture of the atlas, with displacement of the processus
dentatus, and fatal pressure on the  spinal cord, is recorded  by Sir
Astley Cooper.  But one of  the  most  curious and  interesting ex-
amples  of  a fracture and displacement of the atlas is related by Mr.
Benjamin Phillips.   The man, who met with the accident by a fall
from  a  hayrick, lived  forty-seven weeks after the  injury, and  then
died of hydrothorax.   Until the last week of his  life, he was able
to walk to the water-closet.   On  dissection, the condyles of the
occiput were found  yet to rest upon the articulating surfaces of the
atlas; but,  so much of the latter bone, as includes  the surfaces by
which it is articulated  with the occiput  and with the axis, had  been
violently separated  from the posterior portion  of its ring, and carried
downwards and forwards, until it arrived  upon the same plane as, but
anterior to, the axis, to the body and transverse processes of which
it became attached by perfect  bony union, while the posterior  frag-
ment  had suffered no displacement.   The atlas, under these circum-
stances, presented two spinal  foramina, and  four transverse, but no
odontoid process passed through the anterior spinal foramen; and to
the circumstance of its having been fractured, instead of the trans-
verse ligame.it giving  way, Mr. Phillips ascribes the escape of the
man from immediate death.*
   As dislocations of the atlas  from the second vertebra may be set
down as  inevitably fatal, it is unnecessary to say any thing about
their  treatment.  We  do hear, it is true, of  dislocations of the
head  being rectified;  but these are  not the description of cases now
under consideration, but merely examples of the displacement of one
of the articular processes of the  cervical vertebras,  erroneously
called a dislocation of the head.   A cure of such displacement is
possible, and Desault  actually  succeeded in reducing an accident of
this kind,  by fixing the shoulders, and  inclining  the spine in the di-
rection, opposite to that  in which it was thrown.

                 DISLOCATIONS OF THE  RIBS.

   The ribs cannot  well be dislocated at their vertebral extremities;
but a separation   of  the ribs from  their  cartilages   sometimes
takes  place, and then they are generally displaced outwards.   In
Sir Charles Bell's Surgical Reports are the particulars of an inter'
esting case, in which most of  the ribs were dislocated  in this  man-
ner, in consequence of the person being pressed between a post
and a waggon.   Dislocation of a single  rib is sometimes met with.
The proper treatment  consists in the application  of a long  piece of
pasteboard wetted,  so as to fit the part accurately, and over  this a
* See Med. Chir. Trans, vol. xx. p. 78, &c, 
DISLOCATIONS OF  THE  HIP.
385
 broad roller should  be applied, or a piece  of linen, which is to be
 laced.   When the pasteboard becomes dry, it forms an exact case
 for the part, and fits so closely as to prevent all  motion of the end
 of the rib.   Here it is also necessary to bleed the patient freely, as
 there is  a chance of inflammation of the chest, and even of the ab-
 domen;  for  the violence, producing such  a  dislocation, is  always
 great; and, when a  person is jammed between a  wall or a post and
 a wagon, the contusion of parts  is frequently not restricted  to the
 chest.

                   DISLOCATIONS  OF  THE HIP.

    At  this joint, the femur is  liable to  at  least  four dislocations.
 Those, recognised by all surgeons, are the  following:—In thejfirrt,
 the head  of the femur is thrown  upon the dorsum  of the  ilium,
 above the acetabulum and a little behind it, and  under the glutasus
 minimus muscle, with  the trochanter forwards:  this  is by far the
 most common  direction in which the head  of  the femur is dislocat-
 ed.  The next in order  of frequency, is  where the  head  of the
 thigh bone is thrown into  the obturator foramen, or upon the obtura-
 tor externus  muscle, and  the obturator ligament.  In the third dis-
 location, the  head of the femur is thrown inwards  and upwards upon
 the horizontal branch of the  os pubis.   The fourth  is where the
 head of the bone is thrown backwards into the sacro-ischiatic fora-
 men, and is  lodged  on the pyriformis muscle.   In  the fifth case,
 which is  exceedingly rare, the  head  of the femur  takes a  lower
 position, namely, behind the tuberosity of the ischium  downwards
 and backwards.  Such  a dislocation, however  rare, is possible; and
 even those who doubt the possibility of it, caution us, when we are
 reducing a dislocation on  the  obturator foramen,  not  to incline the
 limb too  forward, lest the head of  the  bone should slip into that
 very position.  ^ Sir  Astley Cooper, who never met with such a case,
 cautions us against making  extension, for the reduction of the disloca-
 tion into the obturator foramen, with the limb raised too much in front
 of the axis of the body.   An instance of dislocation downwards and
 backwards, was recorded by Mr. Keate.  In this instance, the lodg-
 ment of the head of the femur behind the tuberosity of the ischium
 arose from a secondary displacement.  A gentleman fell into a ditch,
 with his horse upon him; he lay under the animal for sometime; his
 thigh-bone was  dislocated, and the head of it  was found to have
 been forced  secondarily  behind  the tuberosity of  the ischium.
 However, many surgeons  only admit the possibility of four disloca-
 tions of the thigh, and Delpech is one of them.
  Except where the capsular ligament is much relaxed by the effects
of disease, there must always be, in dislocations of the thigh-bone,
a laceration of the capsular ligament.   There are  instances record-
ed of persons who  could  dislocate the thigh-bone spontaneously,
  vol. «.                  33 
386
PARTICULAR DISLOCATIONS.
and afterwards  replace it  again without assistance.  A gentleman,
who attended my lectures, informed me of a person so circumstanc-
ed, and related some of the particulars to me.   I suppose that, in
such cases, there must be an unusual relaxation of the synovial mem-
brane, a, rupture of the ligamentum teres, and perhaps an imperfect
state of the acetabulum.  But  such examples are rare:  Sir Astley
Cooper mentions one instance; I have heard of other  cases, but I
never saw one  myself.  In most dislocations of the hip, the liga-
mentum teres is ruptured: now, we should suppose, from a mere
anatomical consideration of the joint, that the head  of the  femur
might be dislocated  on the obturator foramen, without  any rupture
of the ligamentum teres; for as that ligament is fixed to  the anterior
inferior part of the acetabulum, it seems to be capable  of allowing
the head of the bone to pass  out of the socket on that side; but it
is a disputed point, whether a dislocation  can take place here with-
out a rupture of this ligament.  Sir Astley Cooper states, that a dis-
location  downwards and forwards, or into the obturator foramen,
cannot take place unless the ligamentum teres be  ruptured, and he
details one or  two  dissections, which corroborate this assertion.
On the other hand, Delpech  asserts, that the ligament is not always
ruptured;  but,  I  believe, this can only be the case, when  some of
the brim of the acetabulum is broken off.   Sir Astley Cooper is of
opinion, that the ligamentum teres is always ruptured in this disloca-
tion, because the accident cannot occur to a living person, except
when his limb is in a state of abduction; and that, in such position,
the ligamentum teres is on  the stretch, and therefore, if the force
applied  go so far as to  dislocate  the joint, the ligamentum  teres
must first give  way.
   With regard to the symptoms of a  dislocation upon the dorsum
of  the  ilium, as  the  head  of the bone  is carried  upwards, there
must be a shortening of the limb; and as it is also thrown backwards,
and the trochanter forwards,  there must be an inversion of the limb;
the knees  and toes will be turned  inwards; the great toe considera-
bly, so  as to  be placed on the  instep of the opposite foot; the
prominence of the trochanter will be diminished,  which necessarily
happens, because the neck of the thigh-bone takes the direction of
the  side of the ilium:  the trochanter is also nearer than natural to
the crista  of the  ilium.   The head  of the bone  can be felt  on the
dorsum  ilii.  The symptoms, then, are,  a  shortening of the  limb;
an inversion of the foot and knee;  and the change in the position of
 the trochanter, namely, its proximity to  the crista of the ilium be-
 ing increased,  and its  own prominence diminished.  The limb can-
 not be  separated  further from  the  opposite  one, but it may be
 slightly bent.
    This dislocation can only happen when the patient has the inferior
 extremity in front of the axis of the  body, with the foot inclined
 inwards.  While he  is in this position, if any great force act on 
DISLOCATIONS OF  THE HIP.
387
the foot or knee,  it will tend to throw the head of  the femur out of
the acetabulum  upon  the  dorsum of the ilium.   Surgeons  have
been much perplexed  to know why, in this case, the toe should al-
ways be inclined  inwards;  they inquire why the head of the femur
should always be thrown backwards, and  the  trochanter forwards.
In this country no explanation has been offered of the fact, or none
that has been admitted as a good one.   In France,  what  has been
considered there as a  satisfactory explanation  of the fact, has been
offered, and is the following:—The lower  and inner part of the cap-
sular ligament, not being lacerated, keeps the great trochanter forward
and the  head of the bone  is therefore always directed backward.
Whether this explanation be admissible or not, it is difficult to say;
hut, in France, surgeons not only account for  the position of the
femur in this dislocation, but in all  the others, in the same manner,
namely, by the consideration  of the way, in  which  the remains of
the lacerated capsular  ligameut act upon the great  trochanter.
   The dislocation upon the dorsum of the ilium, being attended with
a shortening of the limb, might be mistaken for a fracture of the
upper part of  the femur; but  the discrimination  between the two
cases is easy, when it  is recollected  that, in ninety-nine  cases out
of a hundred, the toes are everted in the fracture,  while, in the dis-
location upon  the dorsum  of  the ilium, they are always turned  in-
ward.   Another  difference is, that the limb is altogether less move-
able, or more rigid, in the  dislocation  than in  the fracture.  Then,
in a fracture, even if it be one  of  the neck of the femur,  we may,
on drawing the limb downwards, feel a crepitus, and, on discontin-
uing the extension, the shortening of the limb will immediately recur.
   The next most frequent  dislocation of  the head of  the femur is
that in which it is thrown upon the obturator foramen, or rather on
the obturator externus  muscle,  and obturator  ligament.   Here one
particular symptom is always noticed, viz.  the body is inclined for-
ward by the tension of the  psoas magnus and iliacus internus mus-
cles; the limb is  lengthened from  two  to  four inches;  and in  the
state of abduction, with the knee and  foot widely separated from
those of the opposite limb.  The buttock is flattened in consequence
of the glutasi being drawn downwards, and stretched; and the prom-
inence of the great trochanter is lessened  in   this, as well  as in all
other  dislocations of the hip.    The head of  the  femur is always
plainly perceptible in its new situation, and the trochanter is sepa-
rated further than natural from  the crista of the ilium.   With res-
pect to the position of the  foot in this  dislocation, contradictory
statements  prevail.   Sir Astley Cooper describes the position of
the foot as  being  very  little  to be depended  upon,  and as some-
times but trivially altered, though frequently turned a little inwards.
On the contrary, Delpech  states,  that the foot is  generally turned
outwards.  The  trochanter  should always be particularly attended
to in  this,  and, indeed, in all  dislocations of the femur.   Its  sit- 
388
PARTICULAR DISLOCATIONS.
 uation and  position,  with respect  to  the  crista of the ilium, is a
 point to be strictly  considered;  and,  in  this dislocation,  the dis-
 tance between the two parts is increased.
   In the dislocation, where the head of the bane is thrown upon the
 horizontal branch of the pubes,  the limb  is shortened and turned
 outwards, and the head of the femur is felt, forming a distinct prom-
 inence below Poupart's ligament, and  to the outer side of the femo-
 ral vessels.   This is the  only common dislocation of the hip,  always
 attended with considerable eversion of the limb; for the example of
 luxation behind the tuberosity of the ischium, which  is said  to pre-
 sent the1 same symptom,  is exceedingly rare.
   In the dislocation backwards  into the ischiatic notch, the  limb is
 turned inwards, but not  in so great'a, degree as  in the dislocation
 upon the dorsum of the  ilium; there is also a  slight  shortening of
 the limb, for  the natural  position of the ischiatic notch is  a little
 higher than  that of the acetabulum.  There is likewise  a diminution
 in the projection of the trochanter, and the head of the bone in thin
 persons may be felt in its  unnatural situation, on rotating the thigh
 inwards.
   The  particular  direction, which the head of the  bone takes in
 each variety  of  dislocation, is  determined  by the position of  the
 limb at  the moment when  the force operates that occasions the dis-
 placement.   Thus, there  cannot  be a dislocation into the sacro-
 ischiatic notch, unless the lower  extremity be,  at  the  moment  of
 the accident, elevated in  front of the axis of the body, or  the body
 bent forwards over the thigh.
   In reducing dislocations of the femur, three grand  or  leading
 principles must  constantly  be attended  to;  namely,  counter-ex-
 tension, extension,, and the employment  of  the shaft of the bone as
 a lever for reducing its head.  These are  the principles which are
 of the greatest consequence; for  we cannot fulfil the  principle  of
 relaxing the  muscles  in these cases, because the bone is actually
 fixed in a  particular  position.  But,  though we cannot avail our-
 selves of the  principle of relaxing the  most powerful muscles by
position, it is in our power, when  great difficulty is encountered, to
 weaken them in another way, that is, by bleeding the patient.  We
 may also find it necessary, in some instances, to reduce the force
 of the muscular system by giving nauseating doses of tartarised an-
 timony, by  which means a temporary weakness and  collapse will
 be produced, during which we are enabled  to overcome with facili-
 ty the slight resistance of the  muscles.
   Counter-extension  is  performed by  fixing the pelvis,  which is
 done by means of a girth passed  between the scrotum  and the up-
 per part of the dislocated thigh, and fixed  to a point directly oppo-
 site that towards which the extension  is to  be made.  Extension  is
 generally made in this country at the lower part of the  femur ; but
 abroad, the  lower part of the  limb,  or the  ankle, is  preferred  for 
DISLOCATIONS  OF THE  HIP.
389
this purpose, and thus a longer lever is gained.   The length of the
lever is indeed of great advantage, and hence, I am  not surprised,
that many foreign surgeons  should adopt this method of making the
extension.   The pelvis being fixed in the  manner I  have mention-
ed, by  means of a girth or  table-cloth, we  are  next  to apply the
extending means.   Now, in whatever situation we make extension,
we should adopt some contrivance to prevent the skin from being
chafed; therefore, if we make  extension with a sheet, we must ap-
ply, underneath it, a wet roller ;  if a pulley is used,  there is  an ap
paratus for the purpose, frequently lined with flannel.
   When the dislocation is upon the dorsum of the ilium, the  direc-
tion of the extension ought to be  obliquely  across the other  knee
and of course the  counter-extension should be  made  towards some
point precisely in  the opposite direction.    It is usual,  in reducing
the dislocation upon the  dorsum of the ilium,  for the .patient to be
placed on his back, either on the floor, or  on a four-post bedstead.
Then, if it be the right femur that is dislocated, extension must be
made in a direction obliquely across the  left knee,  with the  pulley
attached to the left post at the foot of the  bed;  while the counter-
extending means are applied to the  pelvis, as already described,
namely, between the scrotum and the dislocated thigh, and fastened
to a point precisely opposite to that towards which the  extension is
to be made.   Now, as the  pulley is fixed   high,  in  this  instance,
the counter-extension girth must be fixed lower down  than the edge
of the bedstead.   As soon as the extension has  been carried  far
enough  for the apparatus to  be tense,  and  the  patient  to feel the
effect of the  power employed,  we should not go on increasing the
force  at random, but  proceed  cautiously and  slowly, lest mischief
should result.  It is best, as soon as the muscles are  put on the
stretch, to wait a little, and  let them  gradually fatigue themselves,
until their power of resistance is lessened.   In short, the  principle
is, not to relax the extending power, but to keep it  up  until the head
of the femur has descended near  the  acetabulum;  but directly it is
low enough for the lever-like  movement to operate efficiently, the
extension ought not to be increased.   W"e  are now to put in prac-
tice the principle of making the  shaft  of the bone a lever for the
reduction of its own head, which is accomplished by taking hold of
the lower part of  the  limb, and rotating  it outwards.   The head
of the bone is thus inclined directly towards the acetabulum by the
lever-like movement of the  limb.  But  supposing great  difficulty
were to be experienced in effecting the reduction  in  this way, we
should then apply a napkin,  or  band, to the thigh below the  groin,
and draw the upper part of the femur outwards with  it, at the mo-
ment that the limb is suddenly  rotated  outwards, and the foot car-
ried a little across the other.   The napkin acts as a fulcrum for the
lever-like movement, and  the reduction is readily aftected.   When
                       33* 
390
PARTICULAR DISLOCATIONS.
the brim of the acetabulum is very high, and the patient particularly
strong, immense difficulty may be encountered in the reduction, un-
less the band  be applied round  the  thigh.  The  principles upon
which  this dislocation of the thigh-bone is reduced  are  therefore
simple; they are  only three, namely, counter-extension, extension,
and the employment of the shaft of the bone as a lever for reducing
its head; the latter being performed by rotating the limb outwards,
and inclining the ankle inwards, as soon as  the extension has been
carried far enough.   This latter manoeuvre will bring the head of the
bone towards the acetabulum; but if unusual difficulty is experienc-
ed, a band should be applied round the upper part of the  thigh, in
order that this portion of the femur may be drawn outwards.   Such
a band is in fact a fulcrum to assist in the execution of the lever-
like movement of the limb.  By these means, the dislocation, if not
of too  long a standing, may always be reduced.
   I  come now to the reduction  of the next most  frequent form of
dislocation of the femur; that  in which  the  head of the bone is
thrown upon the  obturator foramen.  Here the limb is in the state of
abduction,  and, consequently, if extension  were made in the direc-
tion in  which the  limb is thrown, without taking  some precautions
to prevent the pelvis from being drawn to one side, this would in-
evitably happen.  Therefore, the common means of fixing the pelvis
will not be sufficient; itwill be necessary to puta girth or napkin round
the pelvis, to counteract the tendency, which the extension would have
to carry it too far sideways.   In the reduction of this dislocation, then,
two means are made use of for the counter-extension, which, with-
out them, could not be conveniently fulfilled.   The reduction of the
dislocation on  the obturator foramen is a simple proceeding;  in fact,
as soon as the head  of  the bone is dislodged  from  its situation, it
will  generally  return of  itself into its right place, on inclining  the
ankle  inwards.   But  if we  cannot succeed by  this  plan, then
we are to have recourse to the band round the  thigh, in  order to
draw the upper part  of the femur outwards, and  thus a fulcrum is
obtained to promote the effect of the  movement  of the lower part
of the limb inwards.   There is one caution, however, to be observ-
ed in reducing a dislocation upon the obturator foramen, which is,
to be careful,  that,  while we are making extension, the limb does
not incline forward  too much, and the head of the bone slip back-
ward behind the tuberosity of the ischium, and thus constitute ano-
ther form of dislocation, which is sometimes considered to be irre-
ducible, though  I am not aware of the facts upon which  this view
is  founded.
   In the dislocation into the sacro-ischiatic notch, the direction of
the extension  should be across  the  middle of the  opposite thigh.
The patient is most conveniently  placed  on the uninjured  side of
his body.  This  is a more difficult dislocation to reduce, than that 
DISLOCATIONS  OF THE  HIP.
391
upon the dorsum of the ilium.  Hence, we generally  find it neces-
sary to apply  the band round the upper part of the thigh, as a ful-
crum, or rather as a means of raising the head of the bone over the
brim  of the acetabulum.   At the  period of attempting this, we
should also give the lower part of the limb  a twist outwards, by
which movement  the head of the bone will be inclined towards the
acetabulum, with all the force of  a long and considerable lever.
   In the dislocation on the horizontal branch of the os  pubis, the
patient  is also to be placed on his  side;  the pelvis is to be fixed
with the common apparatus,  and  a band applied round  the upper
part of the thigh  for  the  purpose of raising  the head  of the bone
over the brim of  the acetabulum.   The direction of  the extension
ought to be in a  line  rather behind the axis of the body, and,  as
soon as the head of the bone  has been drawn low enough for the
lever-like movement to be put in practice,  then the extension should
cease, or, at all events, not  be increased.  The usual  means are
now to be put in force for completing  the  reduction, namely, the
lever-like movement of the limb, and the use  of the  band  round the
upper  part of the thigh  as a fulcrum.   In  short, all dislocations of
the thigh  are reduced on the same principles; and  whoever under-
stands these well  and  scientifically, can never be at a loss.  Relax-
ation of the muscles cannot be accomplished by position, though it
may be so by the effect of bleeding and nauseating  doses of tartar-
ised antimony.   In many  cases, indeed, and especially in those of
long standing, such means  become important auxiliaries, without
which there would be no chance of success.
   A dislocation downwards and backwards, in which the head of the
thigh-bone is absolutely thrown behind the tuberosity of the  ischi-
um, was seen  by Mr.  Keate, the patient being a gentleman, whose
horse fell with  him into a ditch.   It  appears that the animal lay
upon him for some time—for five or ten minutes—during which  he
continued  struggling  to liberate himself from  his painful  situa-
tion as  well  as  he  could.   From the  particulars,  it seems that
the original dislocation was  upon the  obturator foramen, but  by
a  secondary displacement,  which  occurred  during  the patient's
struggles, the head of the bone was thrown behind the tuberosity  of
the ischium, the very  situation from which Sir Astley Cooper con-
siders that the reduction would have been impracticable.   However,
in this case, the reduction was attended with no very great difficulty;
the bone was first replaced upon  the obturator  foramen,  and  after-
wards,  by pursuing the plans proper for reduction of the dislocation
on the obturator foramen,  the head  of the bone was replaced.   In
this instance, there was abduction of the limb, and  the head of the
bone could be plainly  felt behind the tuberosity of the ischium; the
toes were also turned considerably outwards.  If there be no mis-
take in the account, the case  proves, in  the first  place, the possibil-
ity of such a dislocation; and secondly, so far from its being irreme- 
392
PARTICULAR  DISLOCATIONS.
diable, that there is no great  difficulty in effecting the  reduction.
We also find an enumeration of the symptoms', namely, a lengthen-
ing and an abduction of the limb,  eversion of the toes, and the be-
ing able to feel the head of the bone in  its unnatural situation.
   [A case very similar to tbe above, occurred  under my observation
some years since.  Tbe patient, Mr. E., aged about thirty-five, was a
caulker, by occupation, and the accident  happened while he was at
work under the bottom of a  canal-boat, July 20th, 1831.  The boat was
raised upon props, three and a  half feet long.  • He was standing bent
forward very much, and with  his feet far astride.  Between bis feet
there was lying a piece of  round  timber  a foot  in diameter.  While
at work in this position, the props  gave way, the  boat  came down,
kill in or one of  the workmen, and forcing the patient down by the side
of the timber over which he was standing, in such  a manner that the
left thigh  was placed between it and tbe bottom  of  the boat.  On be-
ing extricated  from this situation, the left limb was found standing at
a right angle with the trunk, the toes were turned a little inward, the
natural form of the nate lost, and the head of the bone distinctly felt
in rotation, in  the perineum, behind tbe  scrotum,  and  near the bulb
of the urethra.
   Reduction was effected without  much  difficulty, and  the patient
soon recovered the use of his joint.—Ed.]

               DISLOCATIONS OF THE PATELLA.

   The patella  is liable to  three dislocations:  first, outwards on the
external condyle;  secondly, inwards on  the  internal  condyle; and
lastly, upwards, with  rupture  of the ligamentum patellae.  There
are also  some  other modes of displacement;  for occasionally the
patella is simply twisted with the  inner edge  forwards and the ex-
ternal one backwards, so as to  form a considerable projection on the
front of the knee; and sometimes  it is thrown on  the external  con-
dyle and twisted round.
   [Dr. John Watson of this city, reports a case, in the N. Y. Journal
of Medicine, for Oct. 1839, in which tbe  patella was twisted upon  its
axis, in  precisely  the contrary  direction  to that mentioned above  ;
that is, the anterior surface looked inward, and the external  edge
looked forward.—En.]
   But the most  frequent  form of  displacement of the patella  is,
where it is thrown flat  upon the external  condyle.   This disloca-
tion is most  commonly seen  in  persons,  whose knees  are  con-
siderably  inclined inwards.  In persons of  this  conformation, we
may  readily conceive, how the  action  of  the  extensors of the
leg will   draw the  bone  outwards.   When  persons are knock-
knee'd as it is called, and the ligament of the patella  particularly
loose, this dislocation is very  apt  to take place, the action of the
extensors of the  leg being often  sufficient  to produce it, without
the aid of external violence.   Sir Astley Cooper relates  the  case
of a young girl brought up to tumbling, in whom the ligaments of 
DISLOCATIONS OF  THE  KNEE.
393
the knee-joint and  patella were  so loose, in each limb, that both
patellas slipped to the outer side of  the external condyle of the fe-
mur,  whenever  the extensors acted.    The dislocation inwards,
however, is generally produced by external violence,  or a blow on
the external edge  of the  patella,  by which it is driven inwards.
Both  these dislocations are reduced on the same principles, namely,
by  relaxation of the  extensors of the leg, and  then  pressing the
displaced  bone  outwards or inwards, according to the  direction of
the displacement.   There is generally no  great difficulty in effect-
ing the reduction.   However,  instances are  known in which con-
siderable difficulty was experienced; and such a case was met with
by Mr. G.  Young, who found, however, that by placing the patient's
foot against his own shoulder, and pressing on the patella with both
hands, while the limb  was in  this  position,  the reduction became
very practicable, though the ordinary method failed.   Owing to the
looseness of the ligaments in certain individuals, and  an extraordi-
nary obliquity of the articular surface of the lower end of the femur,
it is sometimes difficult to  maintain  the reduction after it has  been
accomplished, and  then it becomes  necessary to apply  a roller over
the patella,  in  the figure of 8  manner, in order to keep  it in its
place.  If there were much  swelling, the roller should not be ap-
plied  until  the inflammation had  been  lessened  with  cold  lotions,
purgatives,  leeches, &c.
   When the dislocation takes place upwards, in consequence of a
rupture of  the ligamentum patellas, there is generally a great deal of
swelling about the  joint, for  this dislocation can only be produced
by great and direct violence,  or extraordinary efforts of the exten-
sor muscles, by which the synovial membrane is torn,  and a severe
degree of inflammation commonly follows.   Here also the principle
of relaxing the extensors of the leg should be observed, by placing
the limb on an oblique plane,  extending bfrom the tuberosity  of  the
ischium to  the heel.  We cannot apply a  bandage at first; but after
three or four days, when the inflammation and swelling  are dimin-
ished, a roller should be put round the lower part of the thigh, so
as to  confine the patella as near as possible to the tibia.  After about
three weeks, it is advisable to  have recourse to passive motion  of
the joint;  that is, a person must be directed to bend and extend  it a
little  every day, for the purpose of preventing anchylosis.
   In  one of the volumes of the London Medical Gazette is a case,
in which the patella was not only  thrown outwards upon  the exter-
nal condyle, but twisted, so that the front surface of the bone was
turned backwards,  and its  posterior surface forwards;  but such an
accident is  far  less common, than the simple dislocation outwards.

                 DISLOCATIONS  OF THE  KNEE.

   The  knee-joint does not derive much strength from the conforma- 
394
PARTICULAR DISLOCATIONS.
tion of the bones, but is rendered immensely strong by the number,
the strength, and the arrangement of its ligaments;  so strong, in-
deed, that its dislocations are rare;  no  other joint equally exposed
to external violence being so seldom dislocated.   However,  dislo-
cations of the knee-joint may  take place, and  in four  directions.
The head of the tibia may be displaced inwards  or  outwards; but
when the  dislocation is in either of these directions, it is always in-
complete, and the accident is exceedingly  rare.  Lateral  disloca-
tions of the knee-joint are more uncommon than those in which the
head of the tibia is thrown either  backwards  or forwards.   There
was a case in Guy's Hospital, where the tibia was dislocated back-
wards and the condyles of the femur forwards, and  such pressure
made on the popliteal artery  by the displaced tibia, that the pulsa-
tion of the  anterior tibial  artery  at the instep was  stopped.   All
dislocations of the knee are exceedingly rare,  yet we occasionally
read of them; and perhaps, in the course of twenty years,  there
may be one case brought into a  large hospital.   There  can be no
difficulty in  recognising them; for  the projection of the tibia and fe-
mur will render them sufficiently obvious.  When  the tibia is dis-
located forwards, there is generally some laceration of the gastroc-
nemius and  popliteus muscles.   Sir Astley Cooper met with a case
of incomplete dislocation of  the knee-joint, in  which the external
condyle was thrown off the  head of the tibia forwards, and  the in-
ternal condyle backwards;  and in this  case, he found,  that there
was no  laceration of the crucial  ligaments; but  if the  tibia were
completely dislocated  backwards, then  the crucial and lateral liga-
ments, and the above muscles might be lacerated.
   The principles of reduction consist in bending the  knee, so as to
relax the strong  muscles of the calf; and, while the femur is fixed,
in making extension and pressing the head of the tibia in the  pro-
per direction.
   Dislocation of the condyles of the femur from the semilunar car-
tilages.—Sometimes the ligamentous bands, which fix the semilu-
nar cartilages in their natural  situation, become more  elongated and
relaxed than usual; and this  is particularly  liable  to  be  the  case,
when there is a collection of fluid in the joint;  and under these cir-
cumstances, if the person,  in walking, happens to bring  his foot  in
contact with any obstacle, one or  both  condyles of the femur may
be  dislocated off the corresponding semilunar cartilage or  carti-
lages;   the  result is, that  the   patient   cannot  straighten  his
leg; and  a sudden attack of severe pain in the joint  is felt.   The
plan adopted by Mr. Hey,  consists in forcibly extending  the  limb,
and then bending it as far as possible; this plan I have tried  with
success.   In some cases, however, it will not answer, and  then
other plans may be tried.  One  of these consists in bending the
thigh, and twisting the leg suddenly outwards; this has occasionally
had the desired effect.   Sir Astley Cooper mentions  a patient, who 
             DISLOCATIONS OF  THE  ANKLE  JOINT.         395

could never get the condyles replaced upon the similunar cartilages,
unless he followed this plan; he used to put himself on  the floor,
and then, by bending his thigh,  and twisting his leg outwards, he
was always able to accomplish the reduction  and  procure instant
relief.   When once  this accident has happened, it will be  liable to
recur ever afterwards; hence it is frequently prudent for the patient
to wear a laced knee-cap, so as  to keep  the knee steady and duly
supported.

               DISLOCATION OF THE FIBULA.

   The upper head of the fibula  is rarely dislocated by external vi-
olence: I have never seen a case  thus produced; but a dislocation
of the upper head of the fibula  is occasionally met with  in conse-
quence of disease, and  then it is thrown backwards.  This, how-
ever, is not a common case.  The  treatment consists in  the  em-
ployment of such remedies  as are  calculated  to stop the  morbid
process going on in the  joint,  which  is generally of  a scrofulous na-
ture;  we are to blister  the  part,  and when  we  have stopped the
further progress of the disease, we should perhaps employ compres-
sion to fix the head of the fibula in its  proper place.

              DISLOCATION OF THE ANKLE  JOINT.

   The ankle  joint is frequently  dislocated.   The tibia may be dis-
located off the astragulus  in  four directions.   The most frequent
case is that where the tibia is dislocated inwards, the tarsus being
forced outwards; in  this accident there is a fracture of the fibula
about two inches and a  half or three  inches above the malleolus ex-
ternus, or the lower end of the bone, its most slender part.  There
is a considerable projection of the malleolus internus, rendering the
integuments over it exceedingly tense; the broken part of the fibu-
la inclines inwards towards the tibia; and the  position of the  foot
is altered,  its outer edge inclining upwards, while its  inner edge is
turned downwards,  so  as  to come  in  contact with the ground.
When the accident  is caused by a  person  jumping  from a great
height, that portion of the tibia which is bound  by ligament to the
fibula is split off, and remains connected to  the broken part of the
latter bone, the ligament binding  the fibula to the tibia in this situ-
ation being  so strong, that it does not give way.
   There are  two methods of treating  this dislocation,  though the
plans of reduction approved of by all surgeons are the same; name-
ly, we are to relax the  strong muscles of the calf; this is  an invari-
able principle; and then by making the requisite counter-extension,
and practising extension from the end of the foot, the tibia may be
easily replaced.  But,  whether  the legs should remain in the bent
position, or should be kept extended,  after  the  reduction has been 
396
PARTICULAR. DISLOCATIONS.
effected, seems to be a  point, on which some of the  most experi-
enced surgeons differ.   Sir Astley Cooper is  an advocate for the
straight position of the leg, and for the application of lateral splints,
each having a foot-piece attached to it, in order  to prevent the foot
from  moving to either side.   On  the contrary,  Baron Dupuy-
tren adopts  another plan:  the  foot being  displaced  outwards, he
first applies a thick wedge-shaped cushion at the lower  part of the
inside of the leg, with the thick end downwards, and  over that  he
applies a  long splint; the wedge-shaped cushion is to  fill up the
space between the inner edge of the sole and the splint, which must
extend some way beyond the foot.  Having secured the splint with
a roller above, he next applies a bandage below in  the form of the
figure of 8, and  thus draws the  foot inwards  towards  the  splint,
which serves as a convenient fixed point.
   In  the other lateral dislocation  of the ankle, the  tibia  is thrown
off the astragalus, in the  direction outwards.   This is a rarer acci-
dent than the former; in fact, it cannot happen without the applica-
tion-of immense force;  and, when it does take place,  there is gene-
rally a fracture of the malleolus internus, or  else an oblique fracture
of the lower end of the tibia extending into the  joint.   Sometimes
the astragalus is also fractured, and the fibula  is broken into several
pieces.   The deltoid ligament is unbroken;  but the outer part  of the
capsular ligament is torn.  When the fibula  breaks,  the external
lateral ligament remains entire;   but, if the fibula is not broken, then
the external lateral ligament is ruptured.*   A  violent twist of the
foot inwards may produce the accident.  The position of the foot
is the reverse of what it is in the foregoing case; for it is the outer
edge  of the  foot that comes in  contact with the ground,  while the
inner  edge is thrown inwards and upwards; and the  malleolus ex-
ternus forms an extraordinary projection.   The reduction is effect-
ed on the same  principles as in  tbe dislocation of the  tibia inw7ards,
and therefore comprises  relaxation of  the strong  muscles of the calf,
counter-extension and  extension.   Sir Astley  Cooper adopts the
same  method of treatment  in this as in the dislocation of the tibia
from the astragalus inwards: he puts  the leg  in the extended posi-
tion, and applies lateral splints with foot-pieces.   Baron Dupuytren
also adopts the plan which I have mentioned, as his practice in the
dislocation of the tibia  inwards, but he puts the wedge-shaped pad
and the long splint on the outside of the leg; for  here  the object
is to bind the foot in this direction.
   In  the third dislocation of the ankle joint, the lower head of the
tibia is thrown off the astragalus forwards  upon  the os naviculare;
and there is a lengthening of the heel  and  a shortening of the foot.
The  dislocation may be either  complete or incomplete; the tibia
may be thrown either off the astragalus altogether, or only partially,
* See Sir Astley Cooper's Treatise on Dislocations, ed. 4, p. 236. 
DISLOCATION  OF THE  ASTRAGALUS.
397
half of it  resting upon that bone, and half upon the os naviculare.
In the latter case, the shortening of the foot may be inconsiderable
and scarcely noticed by a careless  practitioner.
  A dislocation  of the  tibia- off  the  astragalus backwards,  with
elongation of the  foot and shortening of the heel, must be very un-
common;  for Sir Astley  Cooper gives  no instance of it in his valu-
able work, and Baron Dupuytren never met with an example of it.

              DISLOCATION  OF THE ASTRAGALUS.

  Another more  interesting kind of dislocation is that of the astra-
galus itself forwards from the os naviculare and os calcis, so as to
form a considerable projection  on the instep.   This is not a very
common accident, but it  sometimes happens.   I have seen no  less
than three examples of it.  The dislocation may be either complete
or incomplete.   The reduction is  sometimes exceedingly difficult;
and when  it cannot be effected, the accident is a serious one; for
the patient is never afterwards able  to put his heel to the ground, and
his ankle remains permanently stiff.  I remember being called in to
a lady who had met with this accident two or three weeks before I
saw her.  Reduction was  quite impossible; she was a fat woman,
and the injury was attended with so much  swelling at first, that the
surgeon who  saw her  directly after the occurrence of the accident,
could not make out the case.    I perceived that it was a dislocation
of the astragalus; and reduction being  impracticable,  she remains
lame, with a stiff instep.
   In  consequence of this dislocation being sometimes  irreducible,
even under the most skilful treatment,  it has been proposed, when
reduction cannot be effected, to remove the  astragalus altogether.
This has sometimes been done; and when it is a case of  compound
dislocation of the ankle joint, accompanied by displacement of the
astragalus, it may be  the best practice to cut away the latter bone;
but, in  simple  dislocations, I think, this proceeding would not be
justifiable.  Of course,  in all cases,  we should first try to reduce
the bone.  The  plan of reduction is  to relax the  muscles of the
calf, extend the foot  as much as possible, and then  press the bone
into its place.  Cases are recorded, in which the skin covering the
displaced bone, inflamed and sloughed, and the bone  became ex-
posed.   In such  a case Sir Astley Cooper divided the ligamentous
connections of the astragalus,  and removed  it: there was not so
much weakness of the joint produced as might have been expected,
and in eleven months  the gentleman, who was the subject of the ac-
cident, was able to perforin  his duties as a cavalry officer, which
implies a considerable power of using the joint.
   Mr. Benjamin Phillips favored me with the particulars of an ac-
cident, in which the  astragalus was dislocated  backwards, and lay
under the tendo Achillis.  Another instance  has  been lately pub-
  vol.  n.                 34 
398                PARTICULAR DISLOCATIONS.

lished,  in which the  astragalus was completely dislocated, without
any change in its relations to the tibia and fibula.*
  * See Dublin Journ. of Med.  Science,  vol. xiv. p. 235.  The patient was Mr.
Richard Carmichael, the justly eminent surgeon of Dublin.
END  OF  SECTION II. 
THE
FIRST   LINES
OF  THE
PRACTICE  OF  SURGERY.
                        SECTION III.


                         OPERATIONS.*

   The following general maxims, in relation to operative surgery,
 deserve attention:—
   1st. Before  undertaking  any capital operation for the cure of a
 disease in one situation,  we ought to  consider whether the  patient
 has any incurable organic affection about him elsewhere ; and  if he
 has, we should decline to operate.   What is  the good of amputat-
 ing.a limb for a diseased joint, when  the patient  is  dying of tuber-
 cular phthisis ? Where the wisdom of performing  an  operation for
 the cure of an external aneurism, when the patient's  doom is alrea-
 dy sealed  by the  existence of an internal  one ?  At all events, no-
 thing but the immediate  destruction of the patient,  if an operation
 were not performed, would  be a vindication for it  under such  cir-
 cumstances.   Even, with respect to some minor operations, it is a
 rule not to perform even them, when the patient is afflicted with any
 incurable internal disease.   Thus, a fistula in ano is not to  be cut,
 a pile is not to  be extirpated, if the patient is  known to labor under
 disease of the liver or lungs.
  2d.  An operation  is  rarely  advisable, unless the  whole of the
 diseased parts can be removed.   When,  however, a tumor is not
 of a malignant character, and only produces  inconvenience by its
 size,  or particular situation, the partial extirpation of it will some-


  * Those for Herniae and various  Diseases of the Eye,  and some  other operations,
bave been already described. 
400
OPERATIONS.
 times relieve the  patient.   The truth of this observation is  often
 exemplified  in operations on the tonsils, in the state of chronic en-
 largement and obstructing  the  communication  between the mouth
 and the pharynx.   When a true exostosis cannot be entirely taken
 away, the partial  removal of it will sometimes afford great relief by
 diminishing its size, and obviating  the ill  consequences of its pres-
 sure on the neighboring organs.   I have  known  the same practice
 extended  to  bronchoceles, which,  by their pressure, were caus-
 ing  obstruction of the  breathing, and  of  the return of blood  from
 the  head.
   3d.  Before resorting to an operation, we should maturely consid-
 er,  whether  there is any  chance  of cure by milder  means; and,
 if the circumstances  of the case afford  time for a trial of them,
 this ought undoubtedly to be made.
   4th. Some diseases,  for which  desperate operations are occa-
 sionally undertaken, are known  to admit,  in a few  instances, of a
 natural cure.   Here  the surgeon of proper moral  feelings, before
 determining to operate, will consider well, whether the patient has
 the  best chance of life from such an operation, or from  the possi-
 bility of a spontaneous cure.
   5th. Operations should not be  rashly performed  with  an entire
 disregard of the state of the patient's  general health.   We should
 inquire into his previous habits and modes  of life, and  the  present
 state of his constitution; whether he be  plethoric;  of a  phlogistic
 diathesis;  of  a very nervous irritable fibre; one, who has  already
 suffered from erysipelas; or who has  any symptoms, justifying the
 suspicion of  the existence of a serious, or incurable, visceral affec-
 tion.
   6th.  When the time  permits, we should bring the patient's con-
 stitution into as favorable a  condition as possible for the operation
 by means of medicine, diet, and regimen.  In particular, the weak
 should, if  possible, be supported and strengthened;  and the robust
 and  plethoric, who are always  predisposed to inflammation, be re-
 stricted for a few  days to low  diet, and have the bowels emptied;
 and, where little blood is likely to  be lost in the operation,  and  the
 operation sure to fail  if inflammation  follow  it,  the performance of
 venesection may be prudent.   The truth of this remark is illustrat-
 ed in the  treatment of cataracts.    As highly sensitive hysterical,
 and  nervous subjects, not only  frequently have violent constitutional
 disturbance after operations, but sometimes die  very suddenly, im-
 mediately or  shortly after their  completion, we should avoid, impos-
 sible, operating on such individuals; or,  if an  operation must be
 done on them, we should apprize their friends of the uncertainty of
the result,  and administer a  cordial, with a dose of laudanum, a little
 while before  the operation  commences.
   7th.  Another rule  is to  let every instrument,  and every article
likely to be required,  be in  readiness and perfect order before  the 
OPERATION OF  TREPHINING.
401
operation is begun: instruments of the best construction; ligatures;
forceps;  tenaculums; sponges; warm and cold water, towels, ban-
dages, &c. &c.
   8th. The patient should not be informed of the necessity of his
submitting  to an operation long before the period of its performance.
The shorter the interval, between the communication of the painful
intelligence to him and  the  performance of the indispensable mea-
sure, the better;  because the mind, brooding on the expected suffer-
ing, too  frequently causes an aggravation of the disease,  and a most
unfavorable derangement of the general health.
   9th. Patients, about  to undergo operations,  should not have any
opportunity of seeing the knives, saws, and other formidable instru-
ments arranged for the occasion.   The principles of humanity would
dictate this precaution,  were it not suggested by the obvious advan-
tage, in a surgical point of view,  of having the patient as free as pos-
sible either from agitation or depression, while the operator is exe-
cuting perhaps a tedious, a delicate, or a very  difficult task.
   10th.  Every  operation that is  well performed, whatever may  be
the time taken up in its completion, is done quickly enough.
   11th.  In the  ligature of arteries,  the removal of tumors, dead
bone, or extraneous bodies, it is advantageous to make a free  di-
vision of the skin; without which, every other  step in the operation
will be  seriously retarded,  and the patient suffer on the whole infi-
nitely greater pain, than if a proper external incision had been made
at once.

                 OPERATION OF TREPHINING.

   The trephine is frequently applied to various bones of the body;
 but, when we speak of the operation of trephining, we  usually sig-
nify that which consists in sawing out a  portion of the  skull, as is
practised in order to enable the  surgeon to raise a part of it produc-
ing dangerous pressure  on the brain; to discharge collections of mat-
ter or blood,  which  have the same effect; to extract a ball, or other
foreign body  lodged under the skull; to remove  a sequestrum,  ex-
tending  through  both  tables; or to extirpate tumors growing from
the surface of the dura mater.
   Every part of the cranium cannot be trephined with  equal safety.
 However, the mere presence of a suture ought not to deter the sur-
geon from making the perforation in any place which seems advan-
tageous.   I believe, also, that the fears, respecting  wounds  of the
longitudinal  sinus, have been vastly exaggerated; and that, if the
situation of a depressed fracture, or extravasation, demanded  the re-
moval of a piece of the skull directly over this vessel, the operation
would be justifiable.   The longitudinal sinus has often  been wound-
ed by spiculae of the cranium, and  sometimes it has  been punctured
with a lancet, in order  to bleed the  patient; yet the hemorrhage was
                          34* 
402
OPERATIONS.
easily stopped with a small compress of lint.*   But, though  I feel
warranted in making this statement concerning the longitudinal sinus,
I am not acquainted with any  facts, showing that hemorrhage from
the lateral sinuses would not prove more serious.   These latter are
much larger;  and as they occupy the deep transverse furrows in the
inner surface  of the os occipitis, a trephine applied over them would
be likely to wound them.f  Velpeau lays it  down as a maxim, de-
duced from various  facts  on record, that the trephine may be ap-
plied over the sinuses as well as to most other parts of the cranium;
but though he has no fear  of the bleeding, because hemorrhage from
a large vein may always be commanded  by  moderate  pressure, he
allows that a  wound of the sinus exposes the  patient to two dangers;
viz.  inflammation of the wounded vessel, and the entrance of air into

   Authors generally  interdict  the application of the trephine to the
anterior inferior  angle of  the  parietal  bone,  on  account  of the
trunk of the  spinous artery of  the  dura  mater  being situated  in a
groove on the inner surface of that part of the skull.  For my own
part, I should  never be afraid of trephining here;  for,  if the above
vessel were wounded, a little lint  introduced into its orifice, would
immediately stop  the  bloeding; or  we might  imitate  Larrey, and
touch the mouth of  the vessel with a heated probe.
   It is a maxim to avoid trephining any part  from which a complete
circle  of bone cannot  be sawn, without  hurting the dura mater.
The inequalities  on  some  parts of the  inner table of the skull, make
attention to this rule necessary.   Thus, the centre of  the forehead
is rather an inconvenient place for the  trephine, because, when the
spine  of the  os frontis is prominent, it  cannot be  sawn, without the
dura mater being wounded by the teeth of the saw.  At all events,
if the surgeon were  to apply the  trephine  to  this part, he  should
complete the separation   of the  bone  with  an elevator,  instead  of
  * Cases in Surgery, by J. Warner, p. 8. edit.  4.; Marchetti, Ob3. 4.  Sharp's
Operat. p. 144.  edit. 3; Pott's Chirurg.  Works, vol. i. p 156—159.  edit, by Earle.
1808.  Even so far back as the torcular Herophiii in a child, a wound of the sinus by
the spicula of bone, though the blood at first spirted out to the distance of two  feet,
and extinguished a candle, did not afterwards give any trouble from hemorrhage,
which did not return when a dossil of lint had been held a little while on the wound.
See Velpeau, De l'Opi'ration du Trepan, p. 129.   This case, be it observed, was  in
a child, and of  course the sinus of less  diameter than in an adult.  In Hargraves'a
Operalive Surgery, however, it is stated, on the authority of Mr. Read, that hemor-
rhage from the  termination of the longitudinal sinus, may always be stopped by very
moderate pressure.
   t Janson contrived to trephine over the lateral sinus without wounding it, and thus
■ucceeded in extracting a ball from the cerebellum.  See Compte Rendu.de ITIutel-
Dieu de Lyon,  p. 47. 1822.  I should not imagine, as M. Velpeau does, that it would
generally be easy to apply the trephine  without wounding the sinus, unless blood or
matter lay between it and the inner table.
   X De POperation du Trepan, p. 132. 
OPERATION OF TREPHINING.
403
making any dangerous attempt to saw entirely through the project-
ing spine.
   Surgical writers caution us not  to trephine over the frontal sinuses,
and, not  without reason; for, if the perforation be continued  in the
direction in which it begins, the  inner table will  be sawn entirely
through  on one side of the.circle,  before the other is at all divided.
However, the outer table may be first removed  with a large trephine,
and the inner table then perforated with  a smaller one, placed even-
ly and perpendicularly on the posterior surface of  the sinus.*
   The trephine cannot be  applied lower down on  the forehead, than
half an inch above the  superciliary ridge of the os frontis, without
risk of injuring the orbit.   If requisite, it  may be  applied  to the
squamous portion of the temporal hone;  for wounds of the temporal
muscles, are not at present so much dreaded  as they were by our
ancestors.   The  unevenness  of  the os occipitis, the  course of the
longitudinal and lateral sinuses, and the way in which a part of this
bone is covered by muscles, have  made surgeons fearful of apply-
ing the trephine to it.  However, there are  two small  spaces on
each side of the groove for the longitudinal sinus, where a trephine
may be safely applied-!  The operation may  even be done  below
the transverse  ridge, near  the foramen  magnum, as a  division of
the attachments of the splenitis and complexus would  not be dan-
gerous, while unrelieved pressure on the cerebellum  would certain-
ly be fatal.|
   When the bone is already sufficiently exposed  I.-y a  wound, the
operation may commence at once;  but otherwise, it is first requisite
to make  room for the application of the trephine by an incision of a
crucial form, or shaped like the letter T or V.  None of the scalp'
should ever be removed.   The  incision should be  made directly
down to  the bone; but, in fractures, attended with separation  of the
edges of the fissure, or with  comminution, the danger of pressing
too hard  with the knife is obvious.
   It would  be dangerous  to apply the trephine  to depressed  por-
tions of the  skull.   The perforation is always to  be  made on that
side of the fracture,  where  the elevator  can he most conveniently
introduced  beneath the depressed  bone  for the purpose  of raising
it.  [\\ cases of extravasation, the perforation  ought  to be made at
the place where there are traces  of violence done to  the scalp, un-
less particular considerations exist against  the  blood  being effused
under.that part of the cranium, as noticed in the remarks on Injuries
of the Head, in the  second section of this work.
   When the scalp has been divided, and loose splinters of the cra-
  * C. Bell's Operative Surgery, vol. i. p. 439.
  \ S^ee Warner's C.wcs. p.  18. Cil. -I.
  X Faivre, Anc. Jo ,rn. e'e >I< d.  t.  lxviii.; Cawprgue, as quoted by Velpeau,  De
1'Op ration du Trypan, p. 130; A. Copland Hutchinson, in Med. Chir. Trans, vol. ii.
p. 104. 
404
OPERATIONS.
nium are found under it, they ought to be taken away with the for-
ceps or finger;  for they can only be regarded as extraneous bodies,
the continuance of which may be productive of dangerous irritation.
Depressed pieces of the skull, causing  bad symptoms, are some-
times completely  detached, and  admit of  removal in the  same
manner.
   In  every instance  of fracture with depression, unattended with
motives for believing that  the  pressure  on  the brain arises partly
from extravasation, provided such  depressed fracture can be raised
with a  pair of forceps, or an elevator,  without applying the trephine,
the latter operation may be dispensed with.
   When a depressed fracture  is exposed, the bone may sometimes
be raised to its proper level with an elevator; and then no necessity
exists for sawing  away any portion of the cranium, unless blood, ex-
travasated beneath it, render such proceeding advisable.  The point
of the elevator is  to be put under the edge of the depressed piece of
bone, and a  fulcrum  for the instrument obtained  on  the  margin of
the adjoining portion of the cranium.   In other instances, the frac-
ture may be so shaped, that the depressed  portion of bone can be
cut across  with one of Hey's saws at  the part connecting it to the
rest of the skull,  and thus be   easily removed, there  being then no
occasion to take  away with the trephine any other  portion  of the
cranium.   Thus, supposing a  depressed fracture to  represent two
sides of a triangle, a simple and straight division of the bone through
the base of this triangle, with  one of Hey's saws, will  enable the
surgeon at  once to remove the broken and depressed piece of bone.
   The  instruments required in the operation are, a scalpel for the
division of the  scalp, three trephines  with crowns of various diam-
eters, and sliding centre pins, capable of being securely fixed with
a screw when  drawn out to the proper  extent.   One of the most
common defects of modern trephines  is, the liability  of the centre-
pin to slip back as soon  as pressure is made on the  instrument,
which is thus rendered  useless.   Every case  of trephining instru-
ments should also contain an elevator, a  pair of forceps, calculated
to remove  the  bone  when sufficiently loosened  by  the  trephine;
Hey's  saws, with the teeth in straight and semicircular rows; a small
brush,  with which the teeth of the saw are to be now and then clean-
ed  in the progress of the operation;  and  a lenticular  knife, with
which any  irregularities of  bone, at the margin of the opening made
with the trephine, are to be removed.   The plan of  scraping away
the pericranium from the part of the seull on which  the trephine  is
about to be applied,  is now condemned, as  more likely to  detach
tl at membrane to a pernicious extent, than really to facilitate the ac-
tion of the trephine.
   The  operation of trephining is divisible into four stages; first,
that in which  the bone is  exposed; secondly  that  in  which it  is
sawn;  thirdly,  that in which it is taken away;  and  fourthly,* that 
OPERATION OP  TREPHINING.
405
in which  other measures are pursued, in order to fulfil the  object
in view.
   On the first, I have but little more to  say.   When the squamous
portion of the temporal bone is to be exposed, the incisions are usual-
ly made in the form of the letter V, with the apex directed towards
the zygoma, so that their direction may correspond in  some degree
to that of the fibres of the temporal muscle.   The flap is then raised
from the point upwards.   Generally,  the bleeding from branches of
the temporal  or occipital artery, caused by dividing the scalp, should
be allowed to continue  a little while, as  having a  beneficial effect
in checking further effusion of blood  in the  head, or inflammation;
but, if the hemorrhage  be profuse, and  the  pulse considerably re-
duced, ligatures will be necessary.
   The removal of a portion of the cranium with the trephine  is per-
formed  as follows: the  centre-pin of the instrument,  having been
made to project moderately  beyond  the level of  its teeth, and se-
curely fixed  by turning the screw, is  to  be  applied to the  central
point  of the circle  of bone, which  it is judged advisable to remove.
The circumstances, which should guide us  in choosing the place for
the trephine in examples of pressure on the  brain from blood or mat-
ter, accumulated on the surface of the dura  mater, have  been ex-
plained in the foregoing section of this work.   (See Injuries of the
Head.)    When the case is a depressed fracture, the centre-pin, the
use of which  is to  steady the trephine, until the teeth  have formed
a  groove,  is  to be placed on  an unyielding  part  of  the  cranium,
with the crown in  a situation, where the  perforation will enable the
surgeon to elevate, or remove  altogether,  the depressed portion of
bone.  As soon as the centre-pin has been  fixed  in the bone, the
sdrgeon turns the crown alternately  to  the  right  and  left  by the
prone and  supine  movements of his hand, observing to make steady,
but moderate, pressure  with the instrument, until a sufficient groove
is formed.   The  centre pin, which  is no  longer  of  any use, and
whose projection  would soon injure the  dura mater,  is now to be
withdrawn, and the action of the trephine  more  cautiously contin-
ued by semicircular movements of it, made alternately to the right
and left.    The sawing may go on briskly at first;  but we are not to
depend upon our  being  able to  distinguish the arrival of the teeth of
the instrument in  the  diploe,  as a criterion of the external table hav-
ing been divided, and of the necessity of now proceeding with great-
er circumspection  and slowness.  At all  events, it is only  in the
middle period of  life, that the  texture of the cranium  is likely to
afford a difference of sensation  and sound on the division of the ex-
ternal table being  completed.   Whether the arrival  of the instru-
ment in  the diploe  can  be perceived or not, it should be worked
with great  caution after &e groove is of  a certain depth, its  move-
ments being executed with briskness  in the  direction of the teeth,
but with little or no pressure.  In this stage of the operation, the 
406
OPERATIONS.
groove is to be frequently examined with a tooth-pick, the flat end
of a probe, or a small thin  piece of steel  for the purpose, usually
contained  in every case of trephining instruments.  If  the perfora-
tion is found to be complete in any portion of the circular  groove,
the action of the trephine is then to be strictly limited to the parts,
where the division of the inner table has not yet  been carried far
enough.   This is  done  by inclining the instrument, as it works, to
the undivided  portion of the circle.
   The cranium having  been  sawn  to a sufficient  depth, the next
business consists in removing  the circular portion of bone.   In  the
previous stage of the operation, the surgeon will be likely to injure
the dura mater, if he aim at  dividing very completely the inner ta-
ble at every point with  the trephine; and  therefore, as soon as  the
piece of bone  seems loose, it  is safer to remove it with an elevator,
or a  pair of forceps, and to  break  its slight  remaining connections
to the rest of the cranium, than run any risk of  lacerating the dura
mater with the teeth of the saw.  Any irregularities at the edge of
the perforation, likely  to irritate the same  membrane, are then to
be removed with the lenticular knife.
   If the case be one of  pressure on the brain, from blood extrava-
sated on  the dura  mater, the  surgeon  will  now  have to consider,
whether the first opening made  will suffice  for the removal of such
blood; if not,  another, or even a third perforation,  may be necessa-
ry.  The same occasion for additional perforations will not so often
present itself when  purulent matter is lodged  under the inner table,
as it always escapes more readily  than blood, and  is  generally less
diffused.
   When there is a  depressed fracture, an elevator is to be intro-
duced under the part of  the  bone which is below  its proper level;
and a fulcrum having been  obtained . either on the edge of the ad-
joining portion of the cranium, or on the fore finger of the surgeon's
left hand,  the  depressed  fragment is to be raised.   Frequently it
is advisable to remove it entirely, which as I have already explained,
can often  be readily done with one of Pley's saws, and then all oc-
casion for  the  removal  of bone with the trephine is  obviated.   If
the case be what  is termed  a punctured or stellated  fracture, the
whole of the depressed piece of the skull may generally be included
within the circle of the trephine, and thus be easily removed.
   In compound fracture with  the depression, unattended, however,
with symptoms of pressure on  the brain, the  bone may be raised to
its proper level  with an  elevator;  but, according  to the  principles
inculcated in my remarks on Injuries of the Head, trephining would
not always be advisable.
   After the operation, the flaps of the scalp  should be laid down,
and light simple dressings applied.  For the prevention or cure of
inflammation,  bleeding, the application  of cold evaporating lotions
to the scalp, and the exhibition of calomel,  tartarised antimony, and
saline purgative medicines will frequently be necessary. 
EXTIRPATION OF THE EYE.
407
  When, on the exposure of the  dura mater, blood or other fluid
seems confined under it, and the membrane presents a dark-color-
ed,  livid, or yellowish color, and a tense prominent appearance, it
should  be cautiously  punctured.   In one instance, where matter was
suspected to be  more  deeply lodged, Dupuytren introduced a bis-
toury more than an inch into the  substance of the  brain, and dis-
charged the abscess;
  In very  young  subjects, the  opening made with the  trephine is
sometimes  gradually, but  only in part,  repaired by osseous matter.
In the  museum of University College is the skull of a person,  who
had been extensively trephined forty years before he died; and, in this
example, nature has filled up almost the  whole  of the deficiency  with
osseous matter.   Repair to this extent demands a great deal of time.
In persons who have lived  ten, twenty, or fifty years after loss of
portions of the cranium, the slow restoration of the bone appears to
have been progressive for  the whole period.   In fifty  years, a tre-
phine hole  is nearly closed by the shelving growth of bone from the
margin towards  the centre.*

                  EXTIRPATION OF  THE EYE.

  Cancer,  medullary tumors, and melanosis,   are the three diseases
sometimes occasioning the  necessity for the operation, for which the
patient should  be prepared by regulation of his diet and the exhibi-
tion of aperient  medicines, so as to lessen the risk of inflammation,
and of the  extension of it to the brain and its  membranes.
  The  patient should be placed in the recumbent position, with his
head properly  raised on a pillow, and held by an assistant.   When
the  extension  of the disease to the eyelids makes their removal ne-
cessary, the mode of opeiating differs  from that which  is adopted
when those parts are to be preserved:  in the first case, two semilu-
nar  incisions are to  be made, the upper one  corresponding to the
line of the superciliary ridge of the os frontis, and  the lower to the
inferior border of  the  orbit, so as to  detach  the eyelids and allow
them to be taken away with the rest of the disease.   If, however,
they should be  merely adherent to the  diseased eyeball, and  not
themselves affected with malignant disease, they should never be
cut  away, but  only separated from their  connection with  the globe
of the  eye.
  First stage.—Supposing the state  of the  eyelids will admit of
their being saved, the first step  consists in making an incision at
least an inch in length through their external commissure, in the di-
rection  towards  the  temple.   The eyelids  are then to  be turned
back, so as to uncover, as it were, the base of the orbit, Loth above
and below  the front of the diseased eyeball.
*tSee Mayo's Outlicoj of Human Pathology, p. 8. 8vo. Lond. 1835. 
408
OPERATIONS.
   Second stage.—In this, the  conjunctiva is to  be cut  through  at
its reflexion  over the globe from the eyelids; and this should be
done very completely at every point of the circumference of the
orbit: indeed, some operators aim at more than  this in  the second
stage of the  operation, and introducing the knife at the  greater an-
gle,  with its edge turned downwards, they carry it close  to the os
ethmoides nearly to the optic foramen, and then convey it in a sem-
icircular direction across the whole  extent of the lower  half of the
orbit, thus dividing the inferior oblique  muscle, the conjunctiva  at
its reflexion, and some fat and  cellular tissue.   Next, the  knife is
introduced again at the nasal extremity of the wound, with the edge
turned upwards;  the superior oblique muscle or trochlears is cut
through; and, if possible, the lachrymal gland  separated, as the in-
cision is passing along the roof of  the orbit.  These two cuts are to
be semilunar, and to meet  at their extremities.
   Third  stage.—As  the  roof of the  orbit is naturally  thin,  and
sometimes is rendered still thinner by long-continued pressure, the
knife, if used incautiously, might penetrate to the brain.   To avoid
this risk, in the division of the  parts at the upper part of the orbit,
the eye should  be drawn downwards with a ligature, or  tenaculum,
passed through the  diseased mass.  The eyeball is now only retain-
ed by a kind of pedicle, composed  of the  four recti muscles  and
optic nerve, which  are to be divided either with  a  pair of curved
scissors or a  curved bistoury.   As the  external  side of the  orbit
slants from without inwards, while the internal  goes directly back-
wards,  this  step  of the operation is most easily  accomplished by
introducing the instrument  at the external  side, as recommended by
Desault and Lawrence.   The  surface of the orbit should now be
carefully examined with the finger;  and if the lachrymal gland, or any
portion  of the disease has  been left behind, it should be removed.
  The bleeding from the ophthalmic artery is profuse, but generally
ceases of itself.  If it should continue in an alarming degree, a  dos-
sil of lint should be held and pressed upon  the vessel for a little time,
after which there  will be no further hemorrhage.   Filling the orbit
with sponge,  lint, &c.  is objectionable, as  producing irritation  and
inflammation; effects highly perilous, as  Mr.  Lawrence justly ob-
serves, in consequence of the direct connection between the sheath
of the optic nerve,  the periorbita, and the dura mater, and  the im-
mediate contiguity of the brain.  The commissure  of the eyelids is
to be united with a  suture; and soft rag, dipped in  water, laid  over
the part.

       REMOVAL OF  THE  SUPERIOR  MAXILLARY  BONE.

  The superior maxillary bone is  liable to several  diseases,  which
begin either in the mucous membrane of the  antrum, in  the  bony
parietes  of this cavity,  or in the  fangs  or sockets of the teeth. 
       REMOVAL OF THE  SUI'ERIOR MAXILLARY  BONE.    409

Sometimes the mucous membrane inflames, and, becoming thicken-
ed, blocks up thy opening, naturally  establishing a communication
between  the antrum and the nasal fossae:  the  result is an accumula-
tion of the  niucuj iu the antrum, a case which, as well as abscesses,
has been already described in the foregoing  section  of this work.
On other  occasions, the  lining' of the antrum secretes a concrete
substance, presenting the  characters  of adipocere.   From the in-
terior of the antrum,  polypi, fibro-cartilaginous, medullary, and vas-
cular erectile  tumors*, may grow;  or its  bony parietes  may  be the
seat of caries, necrosis, and exostosis.
   The operation of removing the superior maxillary  bone is some-
times rendered advisable by the growth of a  fibro-cartilagino'is tu-
mor within it, or of a medullary tumor,  when this  is  entirely re-
stricted  to the antrum, and the patient's general  health good.   Ac-
cording  to  Mr.  Syme, medullary  tumors are more  frequent in the
upper jaw bone, than fibrous ones; and as their  removal from  any
part of the body is often followed  by a return of the  disease in the
part, or its development elsewhere, a guarded prognosis sin uld  be
delivered respecting the success of  the  operation.   The removal
 of the upper  jaw for fibrous or fibro-cartilaginous  tumors,  on the
 other hand, has generally been followed  by a permanent cure.
   The methods of operating  are various; but, whichever is select-
 ed, the  patient is to be placed on  a  firm  seat, with  his  head  sup-
 ported  on an assistant's breast,   who  is to employ his  hands in
 steadying  the head,  and, if necessary, in compressing  the trunk of
 the facial  artery.
   M.  Gensoul,  principal  surgeon of the Hotel  Dieu,  at Lyons,
 claims the merit of having first extended  to  operations on the supe-
 rior maxillary bone the approved  principle in surgery, that amputa-
 tion should always  be performed in the sound parts,  and not in the
 diseased-!  This principle led  him not to be content   with taking
 away a  part of tbe diseased bone, as be contends had been done by
 all his predecessors, inclusive  of  Dupuytren, but induced  him to
 aim at  ihe removal of the whole of it.   M.  Gensoul  was further
 encouraged to perform this operation by considering attentively the
 anatomy  of  the  face.   He saw  that the  superior  maxillary bone
 was  only  firmly fixed to  the  other  bones  of the head at  three
 points:—
    1.  At its nasal or ascending process, and the junction of its or-
  * See Lettre Chir. sur quplqnes Maladies dr. Sinus Maxillaire, par Th. Gensoul, p.
33.  In the case here rt'f'ired to. no return of  ihe disease had taken place live years
after the operation.   " For erectile tumor, occupying ihe maxillary  sinus (Mr. Listen
observes*, the ligature of the common c.irotid of the cor responding side, would be ;l>o
prop-r pr.ictice.'"  Practical Surgery, p. 2t>7.
  t l.ettre Chirurg cale sur quelquts Maladies graves du Sinus Maxillaire et de POa
Maxillaire Inf rieur.  Paris.  8vo.  1H:!3. p.  4. &c. When M. Gensoul was lately
in this country,  I had the pleasure of becoming acquainted with him, and of receiving
from him this interesting publication.
   vol.  n.                    35 
410
OPERATIONS.
Ditar plate with  the os unguis and os planum of tbe ethmoid bone.
   2.  At the orbitar margin of the malar, as far as the speno-maxil-
lary fissure; or, as Mr. Guthrie clearly explains, the superior max-
illary bone on tbe outside, is  " attached  firmly  to  the malar bone
by its malar  process, orbitary  edge, and plate,  as  far back as the
speno  maxillary sinus; but as  in general tbe os malae  should  be
more or less removed, its ascending orbitar process, forming the
outer edge of the orbit, should be well considered."*
   3.  At  the junction of  the two  superior maxillary bones,  and
that of the two palate bones.
   A.  The fourth point of connection, which is through the medium
of the ascending portion of the  palate bone and the  pterygoid pro-
cess of the spenoid, readily  gives way on  depressing the superior
maxillary  bone towards the mouth.
   M. Gensoul reflected,  that no large vessel would  necessarily be
wounded;  that the trunk of  the internal  maxillary artery might  be
easily avoided; and that, if  it were injured, it might be tied, after
the bone  had been removed.!   In the event, however,  of the he-
morrhage  being profuse during the operation, he conceived, that it
might be  commanded  by pressing  the common  carotid  against the
spine.   As for  nerves,  he calculated  that the  superior  maxillary
was  the only  trunk of importance exposed  to injury; and had he
not seen  that it admitted of being cut  through,  he would have re-
nounced the idea of operating, rather than tear that  nerve away.
   GensouVs Method.—A vertical  incision is made  from the great
angle of the eye to the upper lip, which is cut through opposite the
canine tooth.  From the middle of this first ind'sion, or rather from
the point  of it on a level with the base of the nose, a second inci-
sion is  made to within four lines of the  lobe of the ear.   A third
incision is next carried from a point, five or six lines on the tempo-
ral side of the external angular  process  of the os  frontis, down to
the termination of the second wound.  The prolongation  of it much
lower down over  the masseter would divide the parotid duct, and
perhaps occasion a salivary fistula.   The two flaps are then reflect-
ed; one upwards, the  other downwards.  The superior maxillary
bone being thus exposed,  the angular process of the malar  bone is
detached  from the external angular  process of the frontal bone, by
means of  a sharp chisel and mallet, and  the division thus extended
into the spheno-maxillary  fissure.   The  zygomatic process of the
rnalar bone is next divided; and  the superior maxillary  bone being
thus loosened on its outer  side, a broadish chisel is applied below
  * See Lond. Med. Gaz. for 1835, p. 316.
  t In one of Gensoul's operations, the pterygoid branch of the internal maxillary
was wounded; and so it was \a Mr. Guthrie's operation, which was performed in the
manner advised by the former surgeon.  In one example, in University College Hos-
pital, the trunk of the internal  maxillary bled;  but was secured with the utmost fa-
cility. 
        REMOVAL OF THE SUPERIOR MAXILLARY  BONE.     411

 the internal angle of the eye, and the lower part of the os unguis
 and orbitar plate of the ethmoid bone are divided.   The ascending
 process of the superior maxillary bone is now to be detached from
 the corresponding os nasi  with the same instruments.  The surgeon
 then divides with a  bistoury all  the soft parts connecting the upper
 jaw to the ala of the nose; and  after extracting one of the incisor
 teeth, severs  the two superior maxillary bones from one another at
 their symphisis  below  the nostrils with  a sharp chisel.   Lastly, in
 order  to detach the superior maxillary  bone  from the connexion
 which  it has with the pterygoid processes of the sphenoid through
 the palate  bone, and  to break some connections which it may yet
 retain to the ethmoid bone backwards, the chisel is plunged oblique-
 ly into the  tumor from the orbit, so as  to cut through  the superior
 maxillary nerve, which ought never to be lacerated;  and the instru-
 ment is then passed deeply enough to serve  as a lever for depress-
 ing the tumor into the mouth.   This having been accomplished, all
 that remains to be done is, with a pair of curved scissors, or a scal-
 pel, to cut through the attachments of  the palate bone to the soft
 palate.
   Any vessels, requiring  ligatures,  are now to be tied;  and the
 flaps laid down, but not united with the twisted  suture, till an hour
 or two have elapsed, within which period  the force of the circula-
 tion will have  revived, and it  will be seen whether any other vessels
 need  ligatures.   In this country, instead of employing the  chisel
 and mallet, surgeons generally use Hey's saws, and a pair of pliers
 with long powerful  handles.*   The division of the malar bone, in
 the first instance, is  preferred  by M. Gensoul, because productive
 of no  material bleeding,  and of none that falls into the throat.
   Second, or Mr. Liston^s Method.—Supposing the malar bone to
 be involved, incisions must  be  made, so  as to expose freely the
 tumor and  bones where it is  proposed  to cut  them.  One of the
 central incisors is first to be extracted.   The point of the bistoury
 is entered over the external angular process, and the incision is car-
 ried  down through the cheek to  the corner of the mouth.  A  sec-
 ond  incision is made along  the  zygoma, so as to meet  the first.
 Then the knife is pushed through  the integument to the nasal pro-
cess of the superior  maxillary bone, the cartilage of the ala of the
nose is detached from the  bone,  and the lip is divided in the mesial
line.    The flap thus formed is quickly dissected up, and held by an
assistant.   The attachments  of  the  soft  parts  to  the floor of the
orbit,  the inferior oblique  muscle, the  infra-orbital  nerve, &c. are
cut, and the contents of the cavity supported and  protected with a
narrow  bent copper spatula.   With the cutting  bone-forceps, the
  * Messrs. Weiss have invented  cutting bone-forceps, the construction of whose
handles multiplies the power of the blades on a different principle from that of the
length of the former parts. 
412                     OPERATIONS.
zygoma, the junction of the malar and frontal bones at the transverse
facial suture, and the nasal process of the superior maxilla, are cut
in succession.   Then a notch being made with  a small  saw in the
alveolar process, the cutting forceps are placed with one blade in the
nostril, and  the other in the mouth, and the palatine  arch clipped
through.  The tumor is now shaken so as to loosen its connexions,
and the remaining attachments divided with the  knife,  as the swell-
ing is turned down.   The velum  palati is to be carefully preserved,
and, if possible, the palatine arch of the palate bone.  .During these
latter proceedings,  the assistant,  if required,  is to compress the
trunk of the carotid.   " Perhaps," observes Mr. Liston, "■ no ves-
sel may require ligature; the branches of the internal maxillary are
elongated, and  torn from the  tumor in bringing it down; in  fact,  if
the mass is  large, there is no possibility of reaching them with the
knife."  The  void  is then  filled  with lint, and  the  edges of the
wound brought together with the  interrupted or  twisted  suture, but
no dressings are to be applied.   In twenty-four hours some of the
sutures may be taken out, and replaced by narrow strips of plaster.
At the end  of  forty-eight hours,  the other stitches are cut, and the
pins withdrawn.  When the  opening in the palate has  become as
much diminished, as  it is  likely to  be by nature, a plate of metal,
or of sea-horse bone, may be adapted to it.*
   If the malar bone  should not require to be taken away, its connex-
ion with the upper maxilla is to be divided with one of Hey's saws,
and, of course, the incision along the zygoma would be unnecessary.
   Third Method, or that of Professor Regnoli-!—With an ordina-
ry convex-edged bistoury an incision is made  over the middle of the
swelling beginning  near  the  external angle of the eye,  and extend-
ing obliquely downwards and inwards to the commissure of the lips.
If the  facial artery  be  compressed as it ascends over  the base
of the jaw, this first wound  will occasion but little  hemorrhage.
The  soft parts on  each side  of the incision  are then to be de-
tached  from the surface of the tumor, the lateral cartilage and  ala
of the  nose being included  in  the internal  flap,  while the exter-
nal comprehends  all parts situated  between  the  line  of the first
incision and the junction of the  superior  maxillary bone  with  the
zygoma.   By  means of a strong knife, which is struck with a ham-
mer, the surgeon divides  in  succession the  base of the nasal pro-
cess, the lower border of the orbit, the superior maxillary canal
and nerve,  the junction of the zygoma with the malar bone, the con-
nexion of this  with the superior maxillary  bone, and then the alveo-
lar  process.   The  use of the  bistoury is now resumed, and the 
             REMOVAL  OF THE  LOWER  JAW  BONE.         413

 membrane of the palate divided with it as  far back  as  the velum
 pendulum palati; after which  the  strong scalpel is driven with the
 hammer between the two middle incisor teeth, in the direction of the
 middle line, as far back  as the palate bones.   The remaining slight
 connections of the superior maxillary bone are then easily overcome
 by moving it alternately  upwards and downwards, and  by means of
 a  few touches of a  curved bistoury.   The  bleeding  is suppressed
 with ligatures,  or, if necessary, the actual  cautery and the sides of
 the wound are  brought  together with the twisted  suture.   As Pro-
 fessor Regnoli makes only  one incision through the cheek, there is
 less disfigurement of the face after this operation, than after the other
 methods.
   If a great deal of pain and  inflammation  were  to follow any of
 the above-described operations, the patient ought  to be freely bled,
 and  put under  antiphlogistic treatment.  Erysipelas  is one of the
 consequences most to be apprehended.
   That Mr. Liston's plan of operating  is, in every respect,  the
 most eligible, is a fact that  admits of no question.

   REMOVAL  OF THE LOWER  JAW  BONE, OR  OF PART  OF IT.

   Cancer of the lip, extending its ravages to the  body of the infe-
 rior maxillary bone is specified as  one case requiring the excision of
 more or less of the latter part; but, I  believe, the opportunity of
 operating under these circumstances, with  a  prospect of  benefiting
 the patient, will seldom present itself, because, when the disease has
 attained this  degree, the absorbent glands  under the jaw and  in the
 neck will commonly be implicated.  However, if these glands were
 free from disease, and especially if, with this condition, the gums and
 alveolary process  were  the only parts manifestly  invaded, in addi-
 tion to the lip and soft parts near  it,  the  excision of the diseased
 portion of bone, together with  the cancerous affection of the other
 textures would  be an advisable measure.   A  patient in this state was
 referred to me  by the late  Dr. Blicke, of  Walthamstowe:  1 re-
 commended the operation, but believe that it was never submitted to.
   Sometimes the necessity for removing  a  portion of the lower
jaw is  occasioned  by an  epulis  assuming a  malignant character, and
 involving the alveoli  or even a greater extent of the bone.   Tumors,
 originating in the sockets of the teeth, and  presenting an  indurated
fungous texture, with a tendency to bleed,  may also make it neces-
sary to take away a  part of the bone.   But the  diseases,  for whicn
the most considerable portions, and even the whole of the lower jaw,
have been sometimes taken away,  are certain fibrous tumors, com-
mencing in the cancellous structure  of the bone; and  others of-a
medullary character, beginning in  the same situation.  At the pre-
sent day, however, when medullary sarcoma is regarded as an affec-
tion rarely limited to one part, and often  followed  by a relapse,
        "eons  would decline to operate, if the disease were known
                        35* 
414
OPERATIONS.
 beforehand to be of this unfavorable description.   At the same time
 it would not ho- difficult to find instances of the removal of part  of
 the lower jaw fW medullary tumors, where the patients afterwards
 continued  free iVom the disease.   As for tumors of a fibrous struc-
 ture,  expanding  the  bone, and  destroying  its  texture, they are
 cases where the  operation generally frees the patient  permanently
 from  the grievances  under which  he is laboring.   A disease  of
 this kind  will  sometimes  produce a  tumor, reaching from the
 molar  teeth  of one side to   the  ramus  of  the  opposite  side  of
 the jaw, pushing  back the bn.-;o of the  tongue, and throwing out
 a  fungus,  wherever  ulceration  of it  is excited  by  the pres-
 sure of the teeth of the upper jaw.   A sanious, excessively fetid dis-
 charge takes place.   The  lower j nv  is of thrice its natural  size,
 and even greater,  the fibrous mass occupying  very deeply its more
 or less disorganised texture, and at the same  time  filling the aper-
 ture of  the mouth, protruding  beyond it, and sometimes keeping the
 mouth as widely open as the articulation  of the lower jaw  will al-
 low.   The cheek or  cheeks may  also become enormously distend-
 ed, by other projecting portions of the disease.   The introduction
 of food into the mouth,  perhaps,  can only be effected  by drawing
 one of the commissures of the lips towards the ear;  and,  together
 with all these grievances, there is profuse ptyalism, while respira-
 tion, mastication, and the pronunciation of words, are ail seriously
 interrupted.
   Whether the disease be a medullary, or a  fibrous  tumor, or an
 osteosarcoma, it cannot  be destroyed without a surgical operation,
 which varies according to the  situation and the extent of the swell-
 ing.   The prospect of a radical cure in the first of these examples
 is  much less favorable than where the structure of  the  tumor is  fi-
 brous.    In all the following operations, the patient is to sit on a firm
 chair, with the head thrown back, and  supported on  the  breast of
 an assistant, who can  also compress, if necessary, the  facial arte-
 ries as they ascend, in front of the  insertion of the masseter mus-
 cles, or push them backward,  by which means wounding them may
 sometime^be avoided in removing a central portion of the body of
 the lower jaw bone.   The places,  where the bone is to be sawn
 through, should always be determined beforehand, and the teeth in
 those situations removed on the day preceding the operation.
   First  Operation.—When the disease is confined to the alveolary
process, a perpendicular division of the gum with the knife, and a simi-
lar perpendicular division of the alveolary process with a small saw,
 are to be made on each side of the disease.  Then the diseased por-
tion of bone  may be  broken off with  a strong pair  of foic?ps,
 or divded with a  pair  of cross-cutting forceps, as recommended by
 Mr. Liston.   The bleeding, which  is copious, is  to be stopped by
 pressing lint on the part, and, if necessary, dipping the lint previous-
 ly in the tinctura  ferri sesquichloridi.
   Second Operation.—Removal of the  middle part of  the body of 
REMOVAL  OF THE  LOWER  JAW BONE.
415
the bone.—Two  methods  are usually 'described.   In one, particu-
larly recommended where the integuments are healthy, a perpendic-
ular  incision is made  through the centre  of the lower  lip, and
carried  down  through  the skin as  low  as the  os  hyoides.  In
order that this  first perpendicular cut may be  skilfully made, an as-
sistant takes hold  of the  left portion of the  lip, while the surgeon
fixes the right  between the  index  and  middle fingers  of his  left
hand, ami, with the bistoury in his  right, makes the incision through
the lip and the integuments down to  the os  hyoides.   The right
facial artery being now pressed back by the assistant, who supports
the head,  the point  of the  knife is to be  introduced just in front of
the vessel, and a  transverse cut made forwards along tbe  base of the
jaw, till it meets  the first perpendicular  incision.   The same pro-
ceeding is next followed on the left side.   The four flaps, resulting
from the three incisions, are  then to be  detached and  raised from
the bone,  which, according to Dupuytren, may thus be sawn as far
back as the angle on either side, without injury of the facial  artery.
As the  detachment of  genio-hyoid, and genio-hyo-glossi  muscles,
is apt to be followed by retraction  of the tongue into the pharynx,
and  a  sudden  interruption of  respiration,  perhaps  it  is  best  not
to divide their  insertions until  the  bone has  been  sawn  through on
each side.   Or, if they are to be first divided, the displacement of
the tongue into the pharynx must  be guarded  against by passing a
ligature through the anterior part of the fraenum.
   The  bone is to be partly divided with a metacarpal  saw, or one of
Hey's saws, at a point beyond  the limit of the disease on each side,
and  the division completed with one  stroke of a pair of cutting for-
ceps, the handles  of which  should  be long, so as to give the opera-
tor power.   In using the metacarpal saw, he will obtain more room
for its action by placing himself behind the patient;  but, when Hey's
saw is employed,  this direction is not of any importance.
   The central  portion  of  the bone having been thus sawn through
on each side of the disease, is now to  be drawn  forwards and de-
pressed by an  assistant, while the  surgeon  cuts through the mem-
brane of the mouth and other soft  parts behind the  chin,  with the
knife kept close to the  attachments of the muscles  in  that situation.
At the instant when the genio-glossi are divided, some surgeons re-
commend the apex of the tongue to be taken hold  of  with the inter-
vention  of a piece of rag, in order  to prevent this  organ from being
so forcibly  retracted by the glosso-pharyngei muscles, so as to close
the glottis  and bring on the  risk of suffocation.*  A ligature,  passed
through the fraenum, is  a surer plan.
 * With respect to the improvement cf this operation, it seems to me, that with the
idvantii«re of the transverse wound, it is unnecessary to e.\tcnd the perpendicular in-
ision so°low down as the os h\oides.  If, on the di\ision of the genio-hvo-»lossi, the
3n«ue were to bo forcibly drawn back by the glosso-pharyngei, and the glottis closed 
416
OPERATIONS.
   Dupuytren'sfirst Method.—An assistant supports the head on
his breast, and compresses the facial arteries against the rami of the
bone.   The surgeon, standing in front of the  patient, takes hold
of the right side of the lower lip with the left hand, while an assist-
ant does the same to the left  side,  so that the part  may be tense.
An incision is then made through the centre of the lip, and  extend-
ed perpendicularly nearly down to the os hyoides.   The  two flaps
are reflected to the right  and left; and the bone, having been com-
pletely denuded, and fixed, is sawn  through on each side  with a
hand-saw, at the distance from the symphysis prescribed by the ex-
tent  of the disease.   This  part of the  operation would be  more
conveniently accomplished  by making a groove  with  one of Hey's
saws, and then completing the division with a strong  pair of cutting
forceps.  The central  portion of the bone, having been thus de-
tached from the rest of it, is to be pressed downwards and forwards;
and then the lining of the  mouth, and  the muscles connected with
the posterior part of the body of the  bone, and to the  mylohyoid
line, can be readily separated from their attachments with the knife
kept close to the bone.   On cutting through the.origin of the genio-
glossi muscles, means must be taken to prevent the tongue from be-
ing powerfully retracted by the glosso-pharyngei, so  as to close the
glottis and bring on a stoppage of respiration.   By  proceeding  in
the above manner, Dupuytren was able to  saw through the bone on
each  side  within an inch  of the angle, and to  remove a diseased
mass  weighing a pound and a half.*
   A third Method of removing the  central part of the bone, appli-
cable to cases in which  the integuments are so diseased as net to ad-
mit of preservation.—An incision is to commence on each  side of
the jaw, at such a distance  from the symphysis as will insure the re-
moval of the whole of  the diseased  mass.  These incisions are to
be carried down to the os hyoides, where they meet at an angle.
The soft parts are then to be  dissected back from the bone  on each
side,  and the rest of the operation completed according to  directions
already given.   The sides of  the wound  are next to be brought as
near  one another  as circumstances  will admit;  and,  if the  loss  of
skin is not too considerable, they may be put in  apposition and unit-
ed with the twisted suture.
   Fourth  Operation, applicable  to cases in which the disease occu-
pies  a considerable extent, including part  of the  ramus of the jaw.
—Such teeth, as would interfere with the  division of the bone, are
to be previously extracted.   The first  or anterior  incision passes
from  the vicinity of the commissure of the lips,  to a little below the
base of the jaw.
so as to  threaten instantaneous suffocation, tracheotomy should be done without the
least delay,—the measure successfully resorted to by Lallemand, whose patient had
fallen senseles* on the floor.
  * See Lemons Oiales de Ciinique Chirurgicale, par M. le Baron Dupuytren, t. iv.
 p. 640. 
            REMOVAL  OF  THE  LOWER JAW DONE.         417

  The exact points, however, where both theirs/ and  second  in-
cisions ought to begin, will depend upon the state of the disease  in
the directions forward  and  backward.   Sometimes, when a suspi-
cion is entertained that  it may be necessary to take away the con-
dyle, it is right to let the second incision commence as  far  back as
a point in front of, and  a little above, the  lobe  of  the ear, and  to
continue it down  to the angle of the jaw along the posterior  edge  of
the r;:mus.
  The third or horizontal incision may run from the termination of
the second incision,  along the base of the jaw, so as to join  the first
at its inferior extremity.   The facial artery is  now to be secured.
If it has been necessary to make the second  incision far back, no
sooner has the flap been raised, than a  portion of tie parotid gland,
lying under a prolongation of the cervical fascia, is exposed, and,
with the parotid duct itself crossing the masseter, should be left un-
injured.   The masseter having been separated  from the outside of
the ramus, the next thing is to convey the knife, close  along the in-
side of the bone,  so as to cut through  the membrane of the mouth,
and attachments of the muscles in that situation.   In detaching the
mylo-hyoideus from  the oblique ridge  below  the molar teeth, and
the internal pterygoid   muscle from the inside of the ramus of the
jaw, the knife is  to pass close to the bone, in order to avoid injur-
ing the lingual branch of the fifth pair of nerves.
   A perpendicular groove is now to be made, with Hey's saw, in
the outer surface of  that part of the body of the jaw  which it is in-
tended  to divide, and the division is to be completed  with a strong
pair of cutting forceps.  The ramus  is then  to be partly  divided
with Hey's saw,  but, instead of exposing tbe lingual  branch of the
fifth pair of nerves to injury by sawing  too deeply, I recommend the
anterior part of the bone to be pressed outward, whereby the ramus
will be easily broken off at the groove.   If any difficulty be expe-
rienced, the groove should be made deeper with Hey's saw, or the
cutting forceps cautiously applied.
   k appears to  me that, in this operation, the division of the lip
can hardly ever be needed, and, as leading to disfigurement, should
be  avoided.  As Mr.  Liston  directs, the incision may terminate in
the mesial line, about  an  inch from the  free edge of the lip.   His
plan is to make a semilunar incision along  the base of  the jaw, the
borns of the incision pointing upwards, and passing over the spaces
which were occupied by the extracted teeth.
   Fijth Operation, or  that required when the bene is to be removed
at the articulation.—Here  particular care must be taken to  begin
the posterior incision in front of, and a little above, the lobe of the
ear, in  order that  it  may  reach over  the articulation.  A  good
method is that  of commencing the wound  at the point just above
the  articulation,  and  carrying it  first  downward to the angle, and
then horizontally  towards the chin, were it is  to ascend  again:  thus 
418
OPERATIONS.
having a semilunar shape, as  practised  by Mr.  Liston*,  and Pro-
fessor Regnoli, of Pisa-!  The main difference of this  operation
from  that, in which only  a  portion  of the ramus is removed, con-
sists in the proceedings necessary for the disarticulation of the con-
dyle.   The  anterior division of the jaw having been accomplished
according to directions already given, the end of it is to be forcibly
depressed, so as  to bring the  coronoid process below the zygoma,
and  to enable  the surgeon to  cut  through the attachment of  the
temporal muscle.   The  bone then becomes much  more moveable,
and can be used  as a lever for pressing the condyle against the  an-
terior and external part  of the capsular ligament.   This  is to be
opened  at its fore part, the  external lateral ligament descending
downwards and backwards from the  root of the zygoma to the neck
of the condyle  divided,  and  the condyle  itself then twisted out.J
The latter part is then to  be completely detached by passing a blunt-
pointed  narrow-curved bistoury cautiously round the joint,  so as to
divide the rest of the capsule, the  internal lateral ligament,  and  the
external pterygoid muscle.  By cutting the parts in the manner here
directed, all  risk of wounding the  internal maxillary artery, whose
course is a little  lower down, almost in contact  with the inside of
the neck of the  bone will be  avoided.  Neither  will the lingual
branch of the fifth nerve be injured, if, in detaching  the  internal
pterygoid muscle, the edge of the knife be kept as  closely as possi-
ble to the inner surface of the ramus.   If, after the first division of
the jaw,  the bone were found  to be  so weakened  by disease as not
to admit of  being used as a lever,  it  might be necessary to divide
the ramus, and then to take hold of the end of the bone and depress
it with a strong pair of forceps, while the  temporal muscle is de-
tached from the coronoid process.§  The same mode of proceed-
ing would be called for,  were the  surgeon, after the removal of a
portion of the body and ramus, to find that the extent of the disease
rendered disarticulation advisable.
   The arteries wounded, and  often  requiring  ligatures, after opera-
tions  of the  preceding  description, are the  facial and  labial, but
more  frequently the submental, and necessarily some branches of the
temporal and lingual arteries.   When the  bleeding is profuse,  and
comes from  numerous points, Mr. Liston  prefers  passing a liga-
ture under the common trunk of the  internal maxillary and temporal
arteries, at the point where it  emerges from  beneath the  digastric
  * ,: An incision is made from the condyloid  process, down the posterior border of
the ramus, and along the lower margin of the bone, and terminates above the point of
the chin, in the mesial line, at about an inch from  the free edge of the lip."  See
Liston's Practical Surgery, p. 270.
  t Intorno l'Amputatione di Quasi la Meta della Mascella Inferiore, p. 13.  Pisa,
1834.
  X Liston's Elements of Surgery, p. 22$, part 2d.
  § See Hargrave's Operative Surgery, p. 180. 
BRONCHOTOMY.
419
muscle to tying all the branches which pour  out blood.  With re-
gard to tying the common carotid  artery, as  a preliminary measure
in the operation of  removing any part of the lower jaw, it  is com-
pletely superfluous.   WTere it  on  any occasion necessary to check
the flow of blood through the carotid, it might be done by pressing
the artery against the transverse processes of the cervical vertebrae
with an assistant's fingers or thumb.*
   Amongst the accidental consequences of the operation  of re-
moving part  of the  lower  jaw, I  may  mention, 1. Secondary he-
morrhage.  2.  Severe inflammation about the face,  neck, and throat.
3.  Inflammation of the glottis, and  effusion of serum under its lining;
a case in which the  patient sometimes can be saved only by  making
an opening into the  respiratory  tube.   4.  A  difficulty of deglutition,
from the division of the attachment  of the  genio-glossi  muscles-!
5.  Erysipelas.   6.   Tetanus.

                        BR0NCH0T0MY,

Or, the operation of cutting  into the  air tubes, is termed  tracheoto-
my, when  the  opening is made in the  trachea; but  laryngotomy,
when the incision is made in  the larynx.
   The following are some of the  circumstances calling for the per-
formance of one or the other of these operations:—
   1.  Foreign bodies which have accidentally fallen down the glottis
into the trachea, as  a cherry-stone, a bean, a small coin, a bead, an
acorn, &c. In such cases, provided no doubt exist about the presence
of the foreign body in the respiratory tube, the operation ought to
be done without delay, and  this notwithstanding there may be  now
and then  a remission of the symptoms.   A patient, mentioned  by
M. Louis, seemed  so well that he was considered out of danger, yet
he died in three weeks; and another, who lived several years with
a louis d'or in one of the bronchi, was destroyed by it in the  end.
The practitioner should remember, that a temporary cessation of the
difficulty of  breathing, cough,  and general  disturbance of  the sys-
tem, arising from the  foreign body, is usual, and he should not suf-
fer himself to be deceived by it.   On the other hand, let  him not
resort to  the operation, unless there be sufficient evidence of the
foreign body having really descended through the glottis, and that it
has not been coughed  up again.   The moyements of the  foreign
body in  the air-passage frequently cause a  kind  of rattling, which
may be heard.  In cases of doubt,  the stethoscope should  be em-
ployed.
  • See Liston's Elements, part 2d. p. 229.—G. Regnoli, Intorno PAmputatione di
Quasi la Meta della Mascella Inferiore Brevi Cenni, pp. 13. & 20. 8vo.  Pisa, 1824.
  t Dupuytren, Lecons Orales, torn. iv. p. 653. 
420
OPERATIONS.
  2. Polypi, fibrous tumors, and other organised growths in the la-
rynx, causing dangerous interruption of the breathing.
  3. Foreign bodies in the pharynx or oesophagus, occasioning by
their pressure a perilous impediment to  respiration, and not admit-
ting of being immediately either extracted or pushed  down into the
stomach.
  4. An urgent interruption of respiration  from a chronic thicken-
ing of the membranous lining of the larynx, and a consequent dimi-
nution  in the diameter of the glottis.
  5. The same urgent state,  resulting from acute  inflammation of
the same part.   This case,  however, much less frequently requires
an operation, because tbe disease in its early stage generally yields
to bleeding, mercury, and otlur efficient means, and, in its advanced
stage,  mostly proves fatal,  whether the  tra  hea  be opened or not;
not only this tube being blocked  up  with fibrine,  but the  bronchi
themselves  similarly  obstructed, and  the lungs participating in tbe
effects of the inflammation.   At. the same time, it  deserves atten-
tion, that,  even with these facts  admitted, tbe performance of the
operation is sometimes vindicable, as being tbe only  means of  ena-
bling tbe patient to breathe,  and gain a little time  for the further trial
of remedies calculated to subdue the disease; provided there be rea-
son to believe that the inflammation  has  not descended  beyond tbe
first division of the bronchi, in which case the operation would be
useless.   M.  Bretonneau  is  an advocate for  opening tbe trachea
freely, and, besides placing rather a wide cannula  in the wound, to
promote the escape of the layers of fibrine from tbe  trachea, be in-
troduces calomel, either in a dry or moistened  state, into that organ,
for ihe purpose of expediting tbe absorption of the fibrinous deposit.
Several  cases are recorded, in which M. Bretonneau adopted this
practice successfully.   Velpeau refers to a case  under M. Trous-
seau, who,  after performing tracheotomy, and putting a cannula into
the wound, introduced into the  bronchi twenty drops of a solution
of 3 j. of nitrate of silver in § j. of distilled water, every six hours,
for three days  and  a  half.  Twenty  drops of a tepid decoction of
marshmallows were introduced every hour, and the cannula  with-
drawn and  cleaned three times a day.   The child,  aged six years,
continued  for  four days to  void  considerable  portions of fibrine
through  the tube.   On  the tenth day, the air began to pass very
well through the larynx, and,  by the twenty-fifth, the wound in.the
trachea had healed.*   The value of the  practices here alluded to,
 I leave to the judgment of the physician, and merely advert to them
as connected  with the  present subject.
   6.  Various  cases,  in which  suffocation is urgently  threatened
by the mechanical pressure of swellings on  the  larynx  or  trachea,
* Nouveaux Elemens de Med. Ope'ratoire, torn. ii. p. 202. 
BRONCHOTOAlY.
421
provided such pressure cannot be immediately removed, as it often
may be by discharging the contents of abscesses.   In this last man-
ner, I saved a child under Dr. Campbell, of Camden Town, which
was on the point of suffocation from the pressure of a collection of
matter formed around the thyroid gland.
   7. For the purpose  of inflating the lungs in some  examples of
suspended animation, like that resulting from hanging;  for the plan
is  at present nearly abandoned with reference to cases of drowning..
It appears, also, to promise no success, where life is suddenly  ex-
tinguished  by the azotic  principle of certain gases."
   8. Disease of the larynx from syphilis; threatening suffocation.
   9. Dangerous obstruction  of respiration from the effects of in-
flammation of the lining of the glottis,  excited by swallowing boil-
ing  water-!
   10. Complete interruption of  respiration by retraction  of the
tongue into the pharynx, occasionally taking place on the division of
the attachment of the genio-glossi muscles in the  removal  of the
body of the lower jaw.
   In performing tracheotomy, the  surgeon  should recollect the rela-
tive anatomy of the trachea; especially its having the oesophagus
behind it;  its inclination rather to the right side of the neck;  its be-
ing covered,  first, by the common integuments,—secondly, by the
cervical fascia,—thirdly, by the transverse slip of the thyroid gland,
connecting  the two lobes of  this  body, near the cricoid  cartilagej
and lower  down by a  plexus of veins,  some  lymphatic glands, and
the middle thyroid  artery, when it exists,—fourthly,  by the sterno-
hyoid and  sterno-thyroid muscles, which lie towards its side.   The
inferior laryngeal nerves are behind  it, and the common carotid at its
outer side.    Occasionally it is crossed by one of the inferior thyroid
arteries, which then passes from one side  of the neck to the other*
In children,  the arteria  innominata generally lies over  the  front of
the trachea,   till the latter tube  is completely out  of tbe  chest, so
that the right carotid artery then quits the  innominata very high up,
and may be  easily  wounded in the operation.  Velpeau has known
the left carotid come from  the right side, and cross  the trachea to
reach its usual situation.J  Mr. A. Burns has a cast, showing an in-
  * Enlargements of the tonsils and tongue can never require tracheotomy or laryngo-
tomy, as diseased tonsils can be removed, and the enormous swelling of the tongue
from inflammation may bo quickly reduced by making two or three free incisions
along its dorsum.
  t Dr. Burgess, in Dublin Hospital Reports, vol. xxxi. p. 379.—Hargrave's Opera-
tive Surgery, p. 328.  In University College Hospital, tracheotomy has been perform-
ed in several  instances of  this kind; but, generally,  without success.  One  or two
children under me recovered under the free use of calomel.
  X Nouveaux EU'mens de Med Opcratoire, torn. ii. p. 209.  For a description of
■ome anomalies of the arteries in  this part of the body, the reader is referred  to Tie-
demann's  Tabulse Arteriarurn; but a more complete account of the varieties in  the
origins and course of arteries, I hope, will soon be laid before the public by  my friend
and colleague Mr. Quain, whose collection of preparations, illustrative of this subject,
so interesting to the practical surgeon, is, 1 believe, the best in England.
   vol.  ii.                       36 
422
OPERATIONS.
stance of the right carotid  crossing the treachea, two inches and a
quarter,  above the top of the sternum.*
   The trachea, which is superficial above, becomes more and more
deeply situated below, where the front of it is sometimes more than
an  inch  from  the integuments.   So  very moveable  is it likewise,
that, if care be not  taken, the  surgeon, as he is attempting to cut
into it, may push it towards the side of the neck, and the knife in-
jure the  common carotid artery.

                        TRACHEOTOMY.

   The head is to be kept backward, with pillows placed  under the
scapulae.   The surgeon is to be on the patient's right side, in order
that he may with his  left hand feel the  larynx,  and with his right
more  conveniently make the incision from above downwards in the
mesial line of  the neck.   The precise situation of  the cricoid car-
tilage having  been  ascertained,  an incision is to be made  through
the integuments and superficial fascia, from just below the transverse
slip of the thyroid gland downwards to the extent  of at least two in-
ches and a half, or to a point a  little above the first  bone of the
sternum.  In  children, the wound should not extend so far down.
The operator is then  to cut between the two  sets  of sterno-hyoid
and thyroid muscles,  till he comes to the deep cervical fascia, which
is next to be freely divided, and the front  of the trachea itself ex-
posed.   The sterno-thyroid muscles are then  to  be  pushed a little
aside,  and the trachea is to  be prevented,  by the  pressure  of the
surgeon's left forefinger, from suddenly shifting its  place, while he
cautiously makes an opening in the trachea  towards the lower end
of  the external wound, with a  sharp-pointed  scalpel, with its edge
turned upwards, and the point directed  by the nail of the same finger.
Frequently, when respiration is carried on with  difficulty, and the
patient struggles, the  completion  of the latter object is attended with
more  difficulty than the inexperienced might expect;  so rapid and
convulsive, as it were, are the motions of the trachea.   In  a child,
indeed,  the difficulty of the  operation  is great, not merely from
these  causes, but the struggles of so young a  subject, the depth of
the trachea from the  fat in the neck, and the small diameter of the
trachea itself.   Hence  the  plan, now usually followed, of drawing
forward  the trachea of a child with  a  tenaculum, in order to make
an  incision in it, as originally suggested by Dr. James Murray, and
particularly recommended by Mr. Carmichael, I consider  a  great
improvement  of this operation.   A puncture,  or small incision,
having been made in the tube, it is to  be enlarged  to the requisite
extent by cutting from below upwards, either with the same  scalpel,
• See Dublin Journ. of Med. Science, vol. iv. p. 111. 
LARYNG0T0MY.
423
or a curved probe-pointed bistoury.  The knife must  not be car-
ried to the right or left, in order to avoid the risk of wounding the
carotid artery;  and never too near the first bone of the sternum, a
deviation from which rule might endanger the left subclavian vein,
and, in children, even the arteria innominata.
   If the bleeding from the  plexus of thyroid veins were to  be co-
pious, some of them might require ligatures, previously  to the tra-
chea being opened, because the blood would otherwise insinuate it-
self into that tube,  and  seriously increase the  patient's distress.
In general, however, the venous  hemorrhage will soon stop of itself,
and the  surgeon can then safely proceed to open the trachea. How-
ever, if  the case admitted of  no delay,  either the  veins must  be
tied, or, what seems  preferable, the trachea  opened at once,  and
the patient directly afterwards  placed on his side.   Were there a
middle inferior thyroid artery ascending over the  front  of the  tra-
chea,  it  would almost certainly be  divided; and, in this event,  it
should be immediately tied.
   Whether  tracheotomy be  performed to  enable the  patient to
breathe, or for the extraction of  foreign  bodies,  it  is  advisable to
make  rather a free opening in it; because, in the first class of cases,
the cannula*  introduced into the  trachea should be of ample diame-
ter; and, in the  second, nothing will so materially facilitate the pas-
sage of  the extraneous substance outward as an incision of proper
extent.   Frequently, when the sides of the  wound are  separated,
the foreign body is propelled out with the breath, and, if this does
not happen, instruments must be gently introduced, and  the attempt
made to extract it: here a free opening is absolutely indispensable.
In many examples, the foreign body will be found  not  towards the
bronchi, but the larynx.  If not  easily detected, the surgeon should
not irritate the lining of the tube too much  by the  repeated  intro-
duction  of the forceps:  various cases prove, that the  foreign  body
will often be discharged spontaneously after a little while.

                          LARYNG0T0MY.

   The patient's head having been thrown back  to render  the po-
  * The ingenious cannula, described by Mr. Wood in the Med. Chirg. Trans., de-
serves attention; and so do those of M. Bretonneau.  Every surgical praciitioner
should have a set of three tracheotomy tubes of different sizes: they should be curved,
and furnished with ring*, and a rim around their outer end.   It is important that they
should gradually increase in brerrdth from the extremity, which is introduced into the
trachea to the rim, because, with this conical shape, they are adapted to fill and dis-
tend the inci.-ion in the trachea, so as to hinder blood, &c from entering the trachea.
In the  infirmary of the  Fleet Prison, I  lately lost a patient, on whom I performed
tracheotomy, from not  being able at the moment to procure any but a cannula of
wrong construction.  Mr. Lawrence,  instead of the use of a cannula, is in favor of
removing a slip of the edge of the  wound in the trachea; but this is objected  to by
Velpeau, as likely  to cause, after the  opening is finally healed,  an irremediable dim-
inution  in the diameter of the  trachea.  Elem de. Med. Operatoire, torn ii. p. 214. 
424
OPERATIONS.
mum Adami prominent, an incision is to be made through  the skin
and  superficial fascia, beginning over the thyroid  cartilage, and ex-
tending down to the inferior border of the cricoid  cartilage, or  a
little lower.  While the  edges of this wound are held  apart,  the
surgeon  proceeds to  make an incision  in the same  direction, pre-
cisely in the interval  between the two  sets  of sterno-thyroid  and
crico-thyroid muscles.   The crico-thyroid membrane will thus be
exposed.   The  surgeon is now to try whether he can feel the pul-
sation of the small artery, sometimes named the crico-thyroid, and,
if he can, the opening in the  membrane should be  made above or
below it in a perpendicular direction, with the edge turned away
from the vessel.  In most cases, however, the cut should be directed
towards the cricoid  cartilage,  because the small artery, referred to,
generally runs along the lower edge of the thyroid cartilage.
  When the purpose of the operation is  merely to let a  tube be in-
troduced to enable the patient to breathe, a  transverse incision in
the crico-thyroid membrane will suffice; but when the removal of a
foreign body from the larynx is the object,  the  incision should be
made according  to the foregoing description, and  its edges be sep-
arated to let the  extraneous substance escape with the breath, or be
removed with the forceps.
  Writers, who  give the preference to  laryngotomy, offer the fol-
lowing considerations  in its favor: the only parts cut are  the skin,
cellular tissue, cervical  fascia, and  crico-thyroid membrane;  the
little risk of hemorrhage,—a few small veins, and the crico-thyroid
artery, being the only vessels exposed to the knife;  and the greater
facility with which the larynx is fixed,  than the trachea, which  is
also  more deeply situated.
  As to the question, which operation is most suited to the objects
in view, Bichat endeavors  to prove, that laryngotomy  always an-
swers as well as, and  sometimes better  than, tracheotomy.   If the
design were merely to make an opening for the  air, one  situation,
he argues,  would do as well as the other; but if the extraction  of a
foreign  body from the rima-glottidis, or ventricles  cf the larynx,
were required,  laryngotomy  would  be  the most  advantageous.
  While Ferrand  was  surgeon of the  Hotel Dieu,  a  man  was
brought to it  with urgent symptoms  of suffocation, caused by a
stone that had fallen into the glottis.  Tracheotomy was performed,
but merely a little blood  and  mucus was discharged.  The patient
died, and, on examination, a  triangular stone was found, two angles
of which were  lodged in the  ventricles  of the  larynx, while the
other projected at the glottis.   In  this example, laryngotomy would
have saved the man's life.   Wheu a foreign body in the trachea is
loose, it is  mostly at  the upper part of it; but, if it happen to be
fixed, and  lower down, the  advocates for laryngotomy assert,  that
it may even then be readily extracted, by extending the cut through 
PARACENTESIS  THORACIS.
425
the cricoid cartilage, and using a pair of curved forceps.  Notwith-
standing  these  arguments, tracheotomy is usually preferred for the
extraction of foreign bodies, and, as 1 think, justly, because laryn-
gotomy will not  give  the advantage of the  free and  well-placed
opening obtained by tracheotomy.
   Whatever differences of opinion may be entertained, respecting
the advantages  of laryngotomy  for foreign  bodies in the  larynx,
none can exist about the preference which should  be given to trache-
otomy where respiration is  dangerously obstructed by the pressure
of some kinds of tumors on the trachea;  by that of a large foreign
body  in the oesophagus;  or by  the swelling sometimes following
severe wounds  of the  throat.   I also agree with Flajani, in disap-
proving  of  laryngotomy in croup, because  the  wound should be
made away  from the principal seat of inflammation.*
   Surgeons should remember, that in old persons the cartilages of
the larynx are  frequently  ossified, and difficulty would  then be  ex-
perienced in dividing them; and also, that the thyroid cartilage can-
not be slit open in any person without risk of injuring  the chordae
vocales.

                   PARACENTESIS THORACIS,

Or, the operation of making an opening into  an  chest, for the pur-
pose of discharging blood,  pus, a serous or sero-purulent fluid, or
air, confined in the cavity  of the pleura, cannot  frequently be un-
dertaken with much prospect  of  benefit.
   Whether blood  be  effused  from an intercostal artery, or  from
more  deeply  seated  vessels;  whether the bleeding arise from  a
wound, or a spontaneous  rupture of vessels; and whether it be ar-
terial  or  venous; the cessation  of the  hemorrhage can only be
brought about through the formation of coagula, and pressure.   But
if, instead of remaining confined in the chest, the blood  passes out
thro!;di an opening in  the parietes of the chest, coagula will be less
likel^Cb form,  and the hemorrhage in all  probability only terminate
with the death  of the  patient.  Hence, instead  of dilating wounds
of the chest, as the old surgeons sometimes did, the moderns make
it a rule to close them.  If the quantity of effused blood be mode-
rate, it is usually absorbed; and  if very copious, the  stoppage of
the internal hemorrhage can only be accomplished on the principles
above explained, assisted by antiphlogistic treatment.  It is manifest,
then, that the making of any incision or puncture into the chest can
never  be advisable for a recent  extravasation of blood  occasioned
by a  penetrating  wound.   At  a later period, however, when the
vessels have had time to  become obliterated, if  nature  should not
* Flaiani, Collezioni d'Osservazioni e Riflessioni di Chirurgia, t. iii. p. 241.
    J             36* 
426
OPERATIONS.
prove competent of herself to remove the effused blood, and the
symptoms caused by its presence were urgent, it might then be ne-
cessary, and only under such circumstances, to make an opening for
its discharge.*
  With regard to a collection of pus in the chest,  or the case term-
ed empyema, paracentesis  often fails  to be  of service, because in
general the empyema is not the principal, nor the original, disease.
If the  cause  were a tuberculated lung, combined  with vomica, or
any other incurable organic disease of the king; or any serious dis-
ease of the pleura, still going on; the making of an opening  into
the chest would only hasten the patient's death.   On the contrary,
if the suppuration were the consequence of simple inflammation of
the lungs, the operation, as M. Velpeau observes,  might be proper,
if there were nothing in the general condition of the patient prohibi-
tory of it.
  As for a collection of serous fluid,  this is another case in  which
an opening has  sometimes  been  made, though mostly without suc-
cess, because hydrothorax is  rarely  the sole or  original  disease.
It is also remarked  by  Velpeau, that,  in this disease, when the fluid
has been discharged, the  lung is  incapable  of expanding, and the
whole sac of the pleura becomes  filled with air.   Still, if it  were
not certain, that hydrothorax depended upon some  incurable organic
disease, and the quantity of fluid dangerously obstructed the breath-
ing, the performance of paracentesis would  be justified by the re-
sults of certain cases on record.
  Collections of air within the pleura  may arise  from wounds of the
air-cells, from decomposition  of fluids, as is  conjectured, or, from
the simple exhalation of gas from the capillary vessels.   Although
cases of this description may be attended with circumstances vindi-
cating the puncture of the pleura, the result is generally only tempo-
rary relief, because  pneumo-thorax is usually combined with organic
disease in the chest, effusion of blood, or empyema.   If  the air in
the pleura were in moderate quantity, and the cause a wound of the
air-cells, were  the patient  to  live a day or two, the breach  in the
lungs would be closed by the adhesive inflammation;  no more air
would  escape from it; and  what had been already effused  in the
pleura  would gradually be absorbed.
  Whether  the effusion in the chest  be a serous  fluid, or pus, the
case will present certain symptoms common both to hydrothorax and
empyema;  especially short and  difficult respiration, the lungs of
the effected side being compressed by the collection of surrounding
fluid.   In both cases, also, expiration is even more difficult than in-
spiration, on account of the weight of the fluid, which strongly op-
poses the elevation of the diaphragm.   Sometimes, when the patient
* A. L. F. Velpeau, Nouveaux Elemens de Mt'd. Operatoire, torn. ii. p. 250. 
PARACENTESIS THORACIS.
427
 moves in bed, be distinctly feels the undulation.  If the fluid be con-
 tained in only one cavity of the chest, he cannot lie on the opposite
 side, because the fluid compresses the other lung.   The ribs on the
 affected side are more arched  than is natural, because the fluid re-
 sists  their depression.   W~hen no symptoms of suppuration have
 occurred, the case may be suspected to be hydrothorax.   The face,
 the integuments of the chest,  and lower extremities,  are frequently
 oedeniatous,  and  sometimes  also the arm on  the  side affected,
 especially when the quantity of fluid is copious.   Sometimes drop-
 sy of the chest is joined with the same general  affection of the whole
 body.  Ail these symptoms, however, may indicate empyema, when
 preceded by the  usual signs   of inflammation and suppuration in
 the chest.   When symptoms  of acute peripneumony  have taken
 place, and when rigors have occurred at the termination of the in-
 flammatory fever,  just before  the commencement of the above kind
 of symptoms, it is rational  to infer that the case is empyema.  I re-
 member a man in St.Bartholomew's Hospital,whose heart was push-
 ed completely to the right side of the chest, by an abscess in the left
 bag of the pleura.   The  preceding inflammation in the chest, the
 occurrence of rigors, the great difficulty of breathing, and the  pal-
 pitation of the heart, quite on the right side of the sternum, made
 the nature of the case sufficiently evident.  When  the  left  cavity
 of the chest  was  opened after death, an enormous  collection of
 matter  was discovered.    Of late, the  writings of  Avenbrugger,
 Corvisart, Laennec, and  Piorry, have thrown  great light  on the
 mode of ascertaining, not only the presence of fluids  in the chest,
 but their precise situation.   For obtaining correct information on
 these points, the stethoscope and percussion should be resorted to.
 The most eligible place for the operation is between the fifth and sixth,
 or the sixth and seventh true ribs, at the  point just in front of the
 indigitations of the serratus magnus, or midway between the anterior
 and lateral parts of the chest.   In France, paracentesis thoracis is-
 usually performed between  the third and fourth ribs on the left side,
 and between  the fourth and fifth on the right.   An  apprehension of
 wounding the liver and diaphragm by  operating lower down  is the
 chief reason  for this practice.   The French aim at making the in-
 cision at the junction of the posterior  third  with the two anterior
 thirds of the pectoral region.   Here the  opening can  be made just
 in front of the latissimus dorsi, between tbe indigitations of the serra-
 tus  magnus,  and  those of the external oblique  muscle;  and here
 the intercostal artery is still in the subcostal  groove, not having yet
 divided into two branches.
  An incision, two inches and a half  long, should be  made through
the integuments, which are  first to be drawn to one side,  if it be in-
tended to close the wound  immediately after  the operation.   The
intercostal muscles are next to be cautiously divided, and, as soon
as the pleura costalis is exposed, a small  puncture is to be carefully 
428
OPERATIONS.
made in it.   In dividing the intercostal muscles the edge of the
knife should be kept close to the upper  edge of the  lower rib, in
order to avoid  all risk of wounding the  intercostal artery,  which
runs for some way in the groove in the lower edge of the upper rib.
  In emphysema, a small puncture will  suffice; in  hydrothorax it
may be somewhat larger; and, in empyema, the matter must  have
an opening of sufficient  size to allow the  fluid to escape freely
through a  cannula, which,  both in  this  disease and  hydrothorax,
may be furnished with a stopper, which is to be withdrawn as often
as it is deemed advisable to give issue to the fluid in the pleura.

REMOVAL  OF A DISEASED  BREAST,  AND TUMORS  IN GENERAL.

  The manner of removing encysted  tumors has been already de-
scribed.   When  the breast is aftected with any  disease of an incur-
able nature, the whole of the diseased  parts may sometimes  be re-
moved with a knife, the wound healed, and  the  patient's life pro-
longed, or freed from great suffering and annoyance.   The circum-
stances, under which the operation  should be undertaken,  are notic-
ed in the remarks  on cancer.
  If the disease be a scirrhus, some particularity  in  the mode of
operating is requisite.   In this case, the surgeon, instead of merely
removing  parts which  are  palpably and visibly diseased, should
make it a rule to  take away a certain quantity  of the  substance in
the  immediate  circumference of the disease.   Every experienced
man is fully aware of the great propensity of the skin to be affect-
ed, and the frequent extension of white or  yellowish morbid bands
into the surrounding  adipose cellular tissue.  These facts clearly
show the propriety of making a free removal of the  skin, whenev-
er it is in the least discolored, puckered, adherent to the swelling,
or in any way altered, and of taking away a good deal of the fat,
in which scirrhous tumors are involved.   On the contrary,  if the
disease be a mere chronic growth,  or  swelling of the breast, not
of a cancerous nature, the removal of the skin is not  necessary on
this  principle, though it may be so on others, viz. the superfluous
quantity of it, when  the tumor  is very large,  and the difficulty and
tediousness  of the proceedings  for  the removal of such a swelling
when an attempt is made to  preserve the whole  of the integuments.
When cancer recurs,  the  integument is the first part in which it
usually makes its appearance, and the skin of the nipple in  particu-
lar.   Hence, many surgeons always  make  it a  rule to  remove
the latter part,  when it is judged proper to take away any of the in-
teguments.   As Sir Astley Cooper has  observed,  it  is not suffi-
cient to remove the tumor,  but the gland,  from the nipple to  the
tumor, must be removed, and the surrounding parts, to some extent,
taken away.*
* Lectures, vol. ii. p. 199. 
REMOVAL OF  A DISEASED  BREAST.
429
  The patient  is frequently operated  upon in the sitting posture,
but the recumbent has  advantages,  particularly when any gland in
the axilla is to be taken away, or the patient is  likely to faint.   If
the sitting posture be chosen,  the pectoral muscle may be rendered
tense by an assistant keeping the arm back,  which state of the mus-
cle will facilitate the dissection <»f the tumor from its surface.
.  When the case is not of a malignant  character,  and  no  part of
the integuments is to be removed, a straight incision may be made
through them; the tumor is to be regularly dissected  on every side
from the circumjacent  parts; and, lastly, its base is  to be detached,
from above downward, till the whole is  separated.
  If the outer incision  has  been made  more or less transversely,
the lower half of the swelling should  be separated from its surround-
ing connections, before the dissection of the upper portion is begun;
by  which means the surgeon will not be incommoded by the blood
falling into the  lower part of the wound, before the detachment of
the adjacent portion of the tumor is effected.  As soon as the low-
er half of the circumference of the swelling is separated from  its
connections, the surgeon is to undertake the dissection of the upper
half.   Lastly, he is to detach its base from the subjacent textures.
   Such are the modes of removing  all simple  tumors,  which  are
not of a malignant nature, nor of immense size.
   When the tumor  is  malignant, and adherent to  the skin and pec-
toral muscle, the operator is to remove at least an   inch or two of
the fat on every side of the disease.   The portion of the skin,  in-
tended to be taken away, must be included in two semicircular incisions,
which meet thus  ()  at their extremities;  and when the base of the tu-
mor is to be detached, the surface of the pectoral muscle, wherever
it is adherent  to the tumor, is also to be removed.   The advantage
of making the  incision, in  the  preceding manner, obviously consists
in enabling the surgeon to bring the edges of the  wound together
after the operation,  so  as to form a straight line, and admit of union
by  the first intention.
   The mere magnitude of a tumor  frequently renders it highly  ju-
dicious to take away a  portion of the skin: if some  were not  re-
moved, the dissection  would be tedious;  and, after the  operation,
the loose skin would lie in folds, and form, as it were, a large pouch
 for the lodgment of matter.
   In the extirpation of a  diseased breast, the direction  of the ex-
ternal incision must, in some measure, be determined by the shape
of  the tumor:  Desault thought there were  advantages in cutting as
much as possible transversely, when  circumstances would  allow it;
and he believed that, as the integuments were more yielding upwards
or  downwards, than in a  cross direction,  especially near the ster-
num, the  transverse  wound  could  be  more expeditiously united.
These advantages seemed to him of higher importance, than  the
ready escape of matter at the depending  angle  of  the wound;  the 
430
OPERATIONS.
reason generally assigned in favor of the perpendicular direction of
the incision.   At the present  day, these arguments  do  not  sway
surgeons to any great extent; but the direction of the  wound is usu-
ally made obliquely downwards  and forwards, and the base of the
tumor cut from the pectoral muscle in a similar direction, the de-
tachment being first  accomplished at the upper and  outer part of
 he wound, and then regularly extended to its lower and anterior end.
   The tumor having  been removed,  the surgeon should  examine
the interior of the  wound,  in order to  ascertain that  no  indurated
part is left behind; and if any hardness be detected, it ought also to
be removed.   He should  also  examine  the surface  of every scir-
rhous tumor, immediately it is taken out, and see whether any  of the
white bands,  shooting into the surrounding  fat,  have  been divided;
for, in this case, some portion of  those bands must have been left
behind, and ought to be taken away.  Their situation may be known,
by considering the position of  the tumor before the operation.
  When a tumor of the breast has been entirely detached, and the
chief  bleeding vessels tied, which  are usually at the outer part  of
the incision, the arm is to be brought forward.   Then, if there be
any diseased gland in the axilla, the patient should lie down on the
opposite side, and the arm be raised, so that  the arm-pit may be
completely exposed to the light.   For this purpose, the first wound,
if the outer and upper end of  it  be near enough to the axilla, may
be extended over the gland about  to be  taken away;  and the latter
part, having been  separated from  its  surrounding  connections, may
either be cautiously dissected  from the subjacent  parts, or, its base
tied with a bit of strong silk.  The latter method  has  been adopted
by some distinguished operators, in consequence  of the brisk he-
morrhage which takes place from the short arterial branch distributed
to the gland from  the thoracic.   As the axillary vein has occasion-
ally been wounded in dissecting a diseased gland out of the axilla, and
this by skilful and  experienced operators, the plan, now mentioned,
which was generally adopted at  St. Bartholomew's by the late Sir
Charles Blicke, deserves to be remembered.
  Mr. Liston lays down one excellent rule in operations for the re-
moval of tumors.   In all  cases (says  he), the incisions"ought  to
commence at the point where the principal vessels enter; in this
manner, they are divided at the outset,  can he readily secured by
ligature,  or by the fingers of an  assistant, and the  dissection is con-
tinued without risk of further  hemorrhage.   If  the opposite course
be pursued, the vessels will be divided several times during the ope-
ration, numerous ligatures will be required, and  considerable loss of
blood  take place.*
   In  the removal of tumors in general, one rule is,  to make  a free
external incision, which  will materially facilitate and expedite  the
* See Liston's Elem. of Surgery, part  1. p. 222. 
PARACENTESIS  ABDOMINIS.
431
subsequent dissection, and save the patient from the pain and other
ill consequences of a tedious and' protracted operation.   For the
same reason, if a fascia cover the tumor, it should  be freely divi-
ded, so as to make, as it were, an outlet for the morbid mass.
  In dissecting out tumors,  another good general maxim  is,  to cut
as much as possible in the direction of the muscular fibres.

                  PARACENTESIS ABDOMINIS.

  This operation consists in making an opening  into  the cavity  of
the  peritoneum, for the purpose  of discharging  the fluid collected
there in dropsical cases.  The proper instrument for this is a tro-
car, with a cannula through  which the  fluid can readily escape.
  Not many years ago,  it was the invariable  practice  to  introduce
the  instrument at the central  point of a line, drawn from the umbilicus
to the anterior superior spinous process of the os ilium, and on the
left side, in order to avoid all  risk of injuring the liver.   Modern prac-
titioners usually prefer making the  puncture in  the linea alba, for seve-
ral  weighty reasons.   The first is, that, in the other method, no sur-
geon can be sure of introducing the instrument in the exact situation
of the linea semilunaris, and consequently may unnecessarily  wound
the  thick muscular parietes of the abdomen, instead of merely a thin
tendinous part.  Another reason  is, that, in the attempt to tap in the
linea semilunaris, the  epigastric artery has sometimes been wounded
by surgeons  of high repute.   In dropsical  cases, the rectus muscle
is frequently much broader than  in a  healthy subject;  and, as it al-
ways yields to the distension of the fluid in a greater proportion than
the  lateral layers of muscles, the  above measurement is not unlikely
to cause  the wound  to  be made  near  the course of the  epigastric
artery.
  When the operation is to  be performed in the linea alba,  the in-
strument should be introduced about two or three inches below the
navel;  or, as is usually directed,  at the mid point between the um-
bilicus and the pubes.   As  soon as the trocar meets with no further
resistance, it  is not to be  pushed  more deeply, without any object,
and with a possibility of injuring the viscera.  The stilet  is now  to
be withdrawn, the cannula pressed a little further into  the opening,
and the fluid discharged through  it.
  In consequence of tbe sudden removal of the pressure of the fluid
from the viscera and diaphragm, patients are disposed to  swoon,
and even become affected with dangerous symptoms.   In order  to
prevent these unpleasant occurrences, the abdomen is to be com-
pressed with a bandage or belt,  during the discharge  of the fluid,
and afterwards covered with a flannel  compress and roller.
  In cases of ovarial dropsy, the tumor  generally inclines  more
towards one side of the abdomen than the other,  so that  the punc-
ture cannot always be made with  safety in the linea alba.  Here the 
432
OPERATIONS.
custom is to make the puncture at the point where  the swelling is
most prominent, due care being taken, however, to  avoid the epi-
gastric artery.   If, however, the ovarial  cysts  be of great size, it
will frequently admit of a trocar being introduced into it  through
the linea alba with perfect safety.  I have tapped many  ovarial cysts
in both ways.

              REMOVAL OF  A DISEASED  TESTIS.

   In considering the propriety of castration, nothing can be wiser
than the general  maxim,  not  to employ  the knife, if there be any
traces  of disease in the viscera : it may be inferred, that the operation
will not answer when the patient has frequent attacks of colic pains,
a pallid leaden-colored countenance,  indigestion, loss  of appetite,
frequent purging, a hard belly, or any distinct and separate indura-
tions about the abdomen.  In cases of medullary cancer of the tes-
tis, in  consequence of the natural course of the lymphatics of this
organ  to the lumbar glands,  the  absorbent  glands in the course of
the external iliac and common  iliac arteries, and near the aorta, are
frequently implicated.   Sometimes these  form a tumor as large as
a child's head, and perceptible with the hand especially when the
abdominal muscles are relaxed.   The  kidneys also often partake
in the  disease;  and hence, the prudence  of always  making careful
inquiry into the state of those  organs, before venturing to propose
the operation.   It is  to be recollected, however,  that the weight of
the enlarged testis frequently produces in the loins extremely pain-
ful sensations, which  might be mistaken for  symptoms of diseased
kidneys, if the difference were not indicated by  the  pain always di-
minishing, when the scrotum  is well supported in a bag-truss,  or
the patient keeps himself in the recumbent posture.  In such cases,
the state of the urinary secretion would also afford useful light.  If
the scrotum be diseased, there may be enlarged glands in the groin,
which  are  highly unfavorable whenever the  disease of the testis con-
sists of any species  of  tumor characterised by malignancy and  a
disposition to extend  to other organs.
   Attention should be paid to the state of the thoracic viscera; for
experience proves, that various complaints of the chest  frequently
precede or follow the origin of medullary cancer of the testis, and
seem to have  a connection with it.   In fact,  in such cases, the
structure  of the lungs is often  found interspersed  with  pulpy, med-
ullary  tumors.   Hence, when  the  patient  has  a troublesome dry
cough, shortness of breath, and irregular pain in the chest, and es-
pecially when these symptoms attend a medullary tumor of the tes-
tis, the operation is unadvisable.   The success of castration mate-
rially depends upon the state of the spermatic cord; for here it is a
point of the first rate  importance to  remove every particle of the
disease—every thing  which appears unsound and  indurated.   This 
REMOVAL  OF  A DISEASED TESTIS.
433
can easily be accomplished when the disease is confined to the  tes-
tis and epididymis, the cord being unaffected.   But when, as of-
ten happens, the latter part is in the same state as the testis, harden-
ed and enlarged, the operation is improper.  If the disease of the
cord,  however, were not to extend quite up to the ring, and its up-
per portion were still sound, it would yet be practicable to remove
all the parts affected by cutting  the cord through where it is quite
healthy,  and the operation be  justifiable.*  But  it is  not to be
denied that, in such a  case, the event  is  subject to great uncertain-
ty, not so much on account of the commonly feared danger of cut-
ling the cord through near the ring, as  because the extension of the
disease up the  cord is always a ground for apprehending, that  the
complaint will return either in that part, or  in the loins.
    However, unless  the  case  be medullary  cancer,  or  fungus
haematodes, it is  only  when  the cord  is truly scirrhous, that  is to
say, thickened,  hardened, knotty, and painful,  that  it  becomes an
impediment to the operation;  and, when its enlargement is flowing
merely to a varicose dilatation of the veins,  or an effusion of fluid in
the cellular tissue of the part, the circumstance should not prohibit
the use of the knife.   Both these last states of  the spermatic cord
may be distinguished from the  scirrhous alteration  of the cord by
their greater softness, and their diminishing when the patient keeps
himself in a horizontal  position.
   The circumstance of the scrotum  being diseased  is sometimes
deemed nearly  as unfavorable to the   success of  the  operation, as
disease of the cordf,  on account of the distemper  being  likely to
recur in the skin.   However, there is  this  difference,  that  we al-
ways have it in our power to cut away every part of  the  scrotum
which  may be affected, while, in  the case  of scirrhous affection of
the cord, it is sometimes impossible to follow the disorder to its
highest point.
   Castration is one of  the most simple, and yet one  of  the most
painful, operations in surgery, especially when practised according
to the  old method, in which it was the custom to include in the lig-
ature all the vessels and nerves of the spermatic cord.   At the mo-
ment of doing  this, the  patient  was  put  to excruciating torture;
such suffering, indeed,  as few could  endure  without complaint,
however great their fortitude!.
  * A few years, ago, I removed a very large test's for medullary cancer; in the por-
tion of the spermatic cord taken away were sm?jl particles, not larger than millet
seeds, apparently medullary.  Yet the patient nad had no return of the disease four
years after the operation.  A section of the testis, with the cord, is in the possession
of Sir Astley Cooper.
  t Sir C. Bell, Operative Surgery, vo'l. i. p. 223.
  X LeDranappeara to have entertair.ed a just aversion to this painful and unnecessary
plan:  ** Of the several parts of the cord (says he), none but the artery will bleed;
why then should the cremaster uvuscle, the vas deferens, and the nerve be tied with it?,
   vol. ii.                    37 
434
OPERATIONS.
   The hair having been removed from the pubes and scrotum,  the
 first thing is the incision through the  integuments:  it should  com-
 mence a  little  above the  abdominal  ring, and  be  continued  down
 nearly to the bottom of the scrotum.   Two advantages  result from
 extending the cut down to  this point: lodgments of matter, which
 often  seriously retard the cure, will be  prevented; and the  testi-
 cle can be more easily  taken  out.   The  first incision through  the
 integuments will commonly divide the external pudic artery, which
 arises from the crural; and if  it bleed profusely, the best plan is to
 secure it at once with a small  silk ligature, the ends of which may
 be cut short, in the manner practised by  M. Roux.*
   The second  object  is to cut through the sheath of the cord, and
 separate the latter part,  by  making a short incision on  each side
 of it at the point where it is  intended to  divide  it.    When  its de-
 tachment is sufficiently completed to  allow it  to be taken hold of,
 and lifted up, between the  thumb  and forefinger of the operator's
 left hand, this second  step  of the operation is  accomplished.  It
 is a business which should never be  done in a careless way;  for a
 portion of omentum and  a hernial  sac  may  put on  somewhat  the
 appearance of  thickened  cellular tissue, and the protruded part be
 liable  to  injury, or the  hernial sac  might even be  cut through at
 the time of dividing the cordf.
   The third object is the division of the cord; in doing which,  the
 incision should  always be made through  it higher than the extent of
 the disease; for, if this rule  be neglected, the patient will derive no
 effectual relief  from the operation, and  the wound will  either not
 heal up at all, or, if it heal at first, will break out again.   Aware of
 the inutility and pain of including  the  vas deferens in the ligature,
 and of the facility  with which this vessel  can be distinguished at the
 back of the cord  by reason  of its firm feel, some operators pass a
 ligature between it and the rest of the cord, over the front of which
 the knot is made, and they then cut through the cord below the lig-
 ature.   The  agony, however, created by the  inclusion of all the
spermatic nerves, is not only severe, but absolutely  unnecessary in
 a proceeding, the sole aim  of which should be the  security of the
patient from hemorrhage.   A far better plan is to apply no ligature
We are sensible, that convulsive motions have ensued from this method of making the
ligature upon them all."  Operations in Surgery, p. 147, transl. by Gataker, edit. 2d.
  * See Sketches of the Medical School« of Paris, by John G. Crosse, p.  141. 8vo.
Lond. 1815.
  t " After the operation was completed, and the wound dressed, the patient being
seized with  a fit of coughing, to  the astonishment and dismay of the surgeon, the
dressings were forced offby the protrusion of several convolutions of small intestines."
Sir Astley Cooper once removed a  diseased testis, which was accompanied  by a her-
nia.  The bowels were first reduced, and the cord was then separated by dissection
from the back portion of the sac. In Guy's Hospital, he also removed a diseased tes-
tis, to which  the omentum  adhered.  Obs. on the Structure, &c. of the Testis,  p.
164. 
REMOVAL OF A  DISEASED  TESTIS.           435
in any way to the spermatic cord previously to its division; but the
surgeon should hold the part between his left thumb and fore-finger,
just above the point where it is to be divided, and, as soon as it has
been cut through,  the spermatic  artery, and that of the vas  defer-
ens, should  be taken up with a  tenaculum and  tied.  Desault's
method consisted in dividing tbe cord in the preceding manner, and
then holding the  upper end of it between the thumb and fore-finger
of his left  hand, while  with the forceps or tenaculum in his right
hand,  he immediately proceeded to take up the mouths of the sper-
matic  arteries,  and afterwards continued the dissection of the dis-
eased  testis from the scrotum.*
   The fear of a retraction of the remnant of the cord into the in-
guinal canal before  the arteries have been secured, has had a great
deal of influence over the conduct of many surgeons in this part of
the operation; and their alarm has been increased by Mr. B. Bell's
having seen the thing  happen twice in his practice, when both  the
patients were lost by hemorrhage.   But, had the operator, in these
unfortunate examples, been careful to take firm hold of the upper por-
tion of the  cord, before he ventured to divide it, the retraction could
 not have happened;  and, when it did happen in consequence of this
neglect, had he had discernment enough to know what ought then to
have  been done, neither of his  patients would have  fallen a victim
to bleeding.   In short, had he considered the course which the cord
takes obliquely upward and outward, it would have  been easy for
him to have followed the bleeding  part with perfect  safety,  within
the inguinal canal, even  to  the  origin  of the cremaster muscle.f
 The retraction of the upper portion of the cord within the ring must
be more likely to happen, when the extension  of the disease  up-
wards obliges the surgeon to divide the part higher up than will well
allow  the retraction to be securely  prevented by the thumb and fore-
finger of the  left hand.   In  cases of this description, it has been
proposed to avert the accident, by separating the cord into two fas-
ciculi, and, with the aid of a needle, putting a double  ligature be-
twixt them, before the part is cut  through.  The design of this lig-
ature is to draw  down the cord, while the surgeon is taking up the
mouths of the vessels; or, if he cannot thus stop  the hemorrhage,
one portion of the double ligature is recommended to be tied over
the front, and the other over the posterior part, of the cord.J  An-
other plan consists in raising the exposed cord  by  passing under it
the left fore-finger, and then, instead  of  cutting the  part through at
once,  leaving the posterior third of it undivided.   The first incision
 will divide  the principal artery  and its branches,  which are  to be
taken  up singly,  while the weight  of the  testis hinders the part from
• OZuvres Chir. de Desault, par Bichat, torn. ii. p. 451.
|- See Operative Surgery, by C. Hell, vol. i. p. 229.
X Sir C. Bell, vol. cit. pp. 225. 228. 
436
OPERATIONS.
retracting.   Then  the  vas deferens is to  be cut, and, if its artery
be not large enough to require a ligature, the rest of the  cord  is to
be  divided.   I  have usually directed  the  end of the cord  to be
taken  hold of with  a  tenaculum, until its  vessels have been se-
cured.
  That part of the operation, which has for its object the taking of
the diseased testicle out of the scrotum, whether it precede or fol-
low  the  division of the  spermatic cord, is  extremely simple.  It
merely consists in dividing the loose cellular tissue which connects
the testicle with the inside of the  scrotum; and  in performing  this
easy task,  it is proper to incline the edge  of the knife towards the
tumor, which, after the division of the cord, may  be considered as
dead, and destitute of sensation.
  When the diseased testicle is much enlarged,  it is advantageous
to remove  a part of the  distended  scrotum, because a redundant
quantity of loose skin would  otherwise make it  difficult  to put the
edges of incision evenly together,  and is apt  to serve as  a lodgment
for matter.*   The  manner of  executing this object consists in in-
cluding the portion  of the scrotum that is to  be taken away in  two
elliptical incisions, the length  and  interspace  of  which must be reg-
ulated  by the magnitude of the swelling.   Then the spermatic cord
having been divided,  and the arteries secured, the diseased organ is
to be dissected out, the incisions being extended on each side from
the elliptical cuts already made.
  Also when a  part of the scrotum  is ulcerated, thickened, or ad-
herent to the testis, two semilunar,  or elliptical incisions are to be
made,  which meet together above and below, and include  the dis-
eased part  of the skin, which is not to be separated from the  swell-
ing, but taken  away with it.
  When the diseased testicle is of considerable size, it may  lie so
close to the sound testicle  and the penis,  that, if attention be not
paid to the circumstance, and  the  knife be  too  freely  used,  both
these parts may be  injured.   Sometimes,  a part of the tumor is
close to the urethra, and, without  care, this passage might be wound-
ed.   Frequently the swelling presses  closely  against the septum
scroti, which is then  liable to be wounded, and the tunica vaginalis
of the sound testicle opened; an  accident  which may  produce a
good deal  of  inflammation, and therefore ought to be  attentively
avoided.   Former  surgeons  had  great apprehension of wounding
the septum scroti, and the common warning, vociferated  in the ope-
ration, used to be,  " take  care of the septum scroti:"  but the truth
is, if it were not for the chance of laying  open  the opposite  tunica
vaginalis and doing mischief  to the sound testicle at  the same time,
a wound of that part, which  is merely  condensed  cellular tissue,
  * See Sharp's Treatise of the Operations, p. 51. edit. 3.; Bertrandi, Traite des
Operations de Chirurgie, p. 209.  Paris,  1784. 
REMOVAL OF A  DISEASED TESTIS.           437
would be of trivial importance.   There is no surer way of avoiding
the foregoing inconveniences,  than being particularly attentive, in
the dissection of the diseased testis out of the  scrotum, always to
incline the edge of the scalpel towards the swelling.
   The  most  troublesome bleeding  after castration  proceeds, not
from the  spermatic  artery, but  from  vessels within  the scrotum,
which quickly retract amongst the loose cellular tissue;  and though
for a time they may cease  to bleed, they often  begin to  pour out
blood again, directly the force of the circulation returns.   The artery
of the septum scroti, which, in cases of diseased testicles, is often of
greater size than  the  spermatic artery itself*, or  that  of the vas
deferens, should be  sought for and  tied.  In short, as  Sir Astley
Cooper advises, the surgeon should " secure every vessel of the scro-
tum which continues to bleed, or which has been observed to bleed
freely during the operation."!   The ligatures, here used, should be
made of common brown thread, or fine dentist's silk, and cut short
after their application, because the wound always suppurates  more
»r less, and the small  fragments of thread  or  silk contained in it
will come away with the  discharge, without  the  slightest inconve-
nience.
   The operation being finished, the patient should be carried to bed,
and the part then  merely covered with lint, wetted with cold water,
till all apprehension of bleeding has ceased.   After this, the wound
should be more completely closed with two or three  stitches and a
few strips of adhesive plaster.   A compress  of lint may be  laid
over each side of the  incision, and the whole supported with  a T
bandage.  Union by the first intention is here attempted under un-
favorable circumstances;  for it is difficult to maintain the edges of
the wound in exact contact, and  the scrotum, deprived  of the  en-
larged testis, forms a cavity, in which it is hardly  possible to hinder
suppuration.   Some French surgeons, therefore, deny the advantage
of  the above mode  of dressing,  and pursue  the old plan of filling
the scrotum with charpie, and letting the parts suppurate and granu-
late.^:  It is true, complete union by the first intention is seldom or
never accomplished, yet, by attempting it, the  wound is much di-
minished, and  the cure is  rarely delayed later than  three or four
weeks;  whereas  the wound, when stuffed with lint, is  usually not
healed in less than seven or eight weeks.§
   Sometimes, after the patient has been put to  bed, hemorrhage
takes place;  and frequently, when the wound is opened, no partio
• Flaiani, Collezione d'Osserv, torn. 11. p. 151.
t See Obs. on the Structure and Diseases of the Testrs, p. 163. 4to. Lond. 1830.
X Roux, Parallels de la Chirurgie Angloise avec la Chirurgie France, p. 120, &c,

5 J Green Croose, Sketches of the Medical Schools of Paris, &c. p. 144.
                      37* 
438
OPERATIONS.
ular bleeding point can be discovered.   I have generally found the
application of cold  water to the scrotum, by means  of wet  linen,
placed over  the adhesive  plaster, and making the T bandage  some-
what tighter, the best way of checking  the  bleeding.  Should this
plan be  unavailing, however, the dressing must be taken  off, and
the vessels looked for, and tied.   Such  hemorrhage  from the arte-
ries of the scrotum may proceed to a serious  degree, without be-
ing suspected; for the blood sometimes flows out of the  lower an-
gle of the  wound into his  bed, while the outward dressings are per-
fectly dry  and unstained.
   When severe inflammation follows castration, venesection,  leech-
es, and other antiphlogistic remedies are indicated; while much dis-
order of the nervous system, great pain  in the wound, spasms, rest-
lessness, &c. will require  opium and emollient poultices.  Tetanus,
retention  of urine, convulsions,  incessant  vomiting,  tension and
swelling of the belly, peritonitis, abscesses in the course of the cord,
delirium, and incurable fits of  epilepsy; were  more  common after
castration  in former  times, when it was the custom to include th%
whole of the spermatic cord in the  ligature,  than they are  at the
present day.
   After the operation, the upper part of the spermatic cord  occa-
sionally swells so considerably, that it becomes strangulated   by the
abdominal ring,  and vast  suffering is tbe  consequence; a case  which
may require a division of that aperture.*

                   AMPUTATION OF THE PENIS.

   Cancer and mortificationf, of the  penis, are sometimes specified
as  the two cases,  for  which this operation  is required.  That the
first disease is frequently  a proper reason for amputating the  penis,
is unquestionable; but that mortification is so, every  reflecting sur-
geon will  deny.    The mortified  part will separate,  and  the  living
surface cicatrise afterwards, fully as well, as if the patient were  to
submit to  a  painful operation.   I am glad to  have it in my power to
  * Bertrandi, Traite des Operations, p. 209.  Instead of removing a diseased testis,
M. Maunoir tried the plan of exposing the cord and tying the spermatic artery; but,
as he found it sometimes fail, he afterwards had recourse to the method of cutting
the cord completely through, after tbe artery and its branches had been secured.
Another suggestion is that of simply removing a portion of the vas deferens.  The
object of such proceedings is to bring about the absorption of the diseased  testis, but
they are not yet regarded as established practices; and, I apprehend, that their fre-
quent failure will hinder them from being so.
  t In  mortification from paraphimosis, or other causes, the operation is recommend-
ed both by Heister (Institut. Chir. 816.) and  B.  Bell  (Syst. of Surgery,  vol.  i.  p.
538).  Richter deems the operation unnecessary for the separations of the sloughs;
but thinks the knife may sometimes be requisite for  making the end of the  stump
equal, when it has healed with inequalities.  However, beauty seems to me a sub-
ject bere-not worth considering, at least, in a surgical point of view. 
AMPUTATION OF  THE  PENIS.
439
adduce, in support of the foregoing remark, the authority of Loder,
who declares, that, in  examples of mortification,  he would  never
undertake the operation.   When the gangrenous mischief, says he,
is spreading, amputation will be of no use, because it will not stop
the disorder; but if the mortification has ceased to  extend  itself,
the operation will be superfluous, as nature herself will throw off
the dead parts.*
  When the case is a scirrhous, or cancerous disease, the prospect
of a perfect cure will greatly depend upon  the  testicles, skin about
the pubes, and glands in  the groin, being free from  induration.   I
have seen this operation performed three times, and, in  the first in-
stance,  the disease had extended  to  the testicles  and  inguinal
glands;  so that though the patient got rid of the disease,  situated
on the penis, the disorder continued  to  increase in the  groin  and
scrotum, until life was exhausted.
   As the serious mistake  has sometimes happened, of  amputating
the penis for a disease, which, on further examination, appeared to
be of a  very simple and curable nature,  surgeons cannot be too
cautious in the investigation of the  circumstances  of  the complaint
for which the operation is proposed.  In particular, they must care-
fully distinguish the cancerous disease of the penis from the more
common  warty excrescence.   " I have seen  (says Sir  Charles
Bell) a  man just  about  to lose his penis,  on account  of  a combina-
tion of  phimosis  with  these warty excrescences from the glans, and
which had burst through the  prepuce with  a malignant-like distor-
tion.   But the prepuce being freely cut  open,  the luxurient  crop
of harmless warty excrescences started  forth."f
   It  is certainly true,  also,  that the penis has been cut off, when
the prepuce or integuments were the only diseased  parts.   Accord-
ing to the investigations of M. Lisfranc, when  cancer is situated in
the body of the penis, at its root, or even on the scrotum, it com-
mences in the skin, and the subjacent fibrous textures long impede
its progress more deeply.  Hence,  in many instances, the  possibil-
ity of saving the organ by merely removing the integuments.:j:  What
are  commonly termed venereal warts,  are well described by Sir
Charles Bell:'they have a spreading, mushroom-like top, and  slen-
der base; and if  the intermediate parts can be seen, they retain their
natural  appearance.   A tubercle, formed on some part of  the pre-
puce, is often the beginning of cancer of the penis; it is at first, as
Sir Charles Bell  remarks, an  irregular warty excrescence, with  a
broad base in the substance of the prepuce, or on  the fraenum.   In
a more  advanced and ulcerated  stage, the sore is of a dark red co-
lor, covered with a sanious discharge; its bottom i- solid, and deep
* Chir. Med. Beobachtungen, p. 79.
t Operative Surgery, vol. i. p. 130. 8vo. Lond. 1807.
X See J F Malgaigne, Manuel de Med. Operatoire, p. 639. 12mo. Pans, 1834. 
440
OPERATIONS.
excavations, and irregular  cauliflower excrescences, present them-
selves.   The neighboring skin, of a purple color, indurated, swell-
ed, and tuberculated, stands  out from the sore, while  its irregular
edge is turned inwards.   The discharge has a peculiar smell, being
highly offensive;  and when  the urethra  is ulcerated, the urine gushes
out from preternatural openings.*
  Cancer may also commence upon the glans, as happened in the
first case, in which 1 had an opportunity of seeing amputation of the
penis performed.  Here also the disease usually begins  in  the form
of a wart, or small,  not very troublesome,  induration, which gradu-
ally changes into most painful ulcerated excrescence.   Sometimes,
as Richter informs us, the greater part  of the penis  is covered with
such excrescences, the cancerous nature of which is particularly in-
dicated by the deep  extension of their  bases into the substance of
the parts from which they grow, the parts appearing for  some depth
to be converted  into a similar hardened mass to themselves.  I have
seen the whole glans, and part of the corpora cavernosaf,  changed,
in this manner, into a firm incompressible substance,  which had been
gradually extending itself for years, the glands in the groin being also
diseased in  the same way.
   Sometimes, after  the prepuce has been slit open  for the relief of
a congenital phimosis, a large irregular fungus sprouts out  from the
extremity of the  penis, and  continues  spreading until it has  occu-
pied all that part of the organ, which naturally projects beyond the
scrotum.   Frequently, in these circumstances, neither the prepuce,
nor the glans, can be distinctly perceived;   but the whole projecting
part of the penis forms a confused mass of irregular granulated flesh,
discharging  a very foetid  matter.!   It  would appear, from several
of the  cases recorded  by  Mr.  Hey, that tubercles,  or excres-
cences, actually existed within the prepuce before the operation, and
were found  there as  soon as the phimosis was cut.§   What is like-
wise remarkable, is the great  frequency with which the cancerous
disease of the penis  seems to be  attended with, or preceded  by, a
congenital phimosis.   Mr. Hey found  this  to be  the case  in  seven
out of nine  examples which fell under his notice, and (says he)
"where I  had  an  opportunity of seeing  the  disease in an early
stage, the phimosis evidently appeared to have been caused  by an
unnatural formation of the internal membrane of  the prepuce;  and
this formation seemed also to have given rise to  the cancerous af-
fection."   The facts brought  forward by  this  gentleman  tend to
prove, that  this  malignant  affection mostly commences upon the
  * Op. cit. vol. i. p. 131.
  t See case in Hey's Practical Obs. in Surgery, p. 463. edit. 2. A specimen of this
kind, taken from a patient under me at the Bloomsbury Dispensary, is placed in the
Museum of University College.
  X See Hey's Practical Obs. in Surgery, p. 461. edit. 2.
  § See Cases, Op. cit. p. 463. 473. &c. 
AMPUTATION OF  THE PENIS.
441
.  prepuce; and  that, in  its earliest stage, the whole lining of that
  part is studded with minute tubercles, or inequalities, which change
  into the  worst kind of disease.
     According to  Mr.  T ravers, a malignant ulceration  of the  pre-
  puce and penis, following phimosis, and  requiring amputation, may
  he brought on by an indiscreet perseverance in  the use of mercury
  during the period of inflammation.*
     Whenever excrescences on the penis have  a narrow base, they
  may be  cured by cutting  them off, and the amputation of that  or-
  gan  is totally unnecessary,  and,  of course,  improper.f   This  I
  consider more judicious treatment than applying to them  a solution
  of bichloride of  mercury and opium for  their cure, under the idea
  of their  being venereal.   Also, when the wart or excrescence is of
  a  malignant kind, but limited  to the  prepuce,  a cure may generally
  be effected  by a removal of the  part, without  touching  the  glans
  or body  of the penis itself.|   Lastly, it  is to  be recollected,  that
  diseases  of this organ,  which put on a  malignant  appearance,  are
  sometimes cured by the carrot-poultice§, and  the  internal and ex-
  ternal use of arsenic.
     In the operation, the  plan of saving as  much of the penis, and
  also of the  glans, as circumstances will allow, with due regard  to
  the entire removal  of every particle of the disease,  is undoubtedly
  entitled to commendation; because the longer  the stump is left, not
  only the  more  conveniently will the urine afterwards be  discharg-
  ed, but even the  faculty of generation be  more likely to be pre-
  served.   In  confirmation  of the latter point, the testimony of Heis-
  ter might be adduced,.and Loder mentions one example, in which
  the patient retained the power of propagating after amputation  of
  the whole of the glans.||
     Amputation of a cancerous affection of the penis often brings about
  a cure, relapses being much less frequent than  after the generality of
  operations for the removal of cancerous parts.  In  the three  first
  cases published by  Mr. Hey, the  cure after the operation  was per-
  manent.IF  In order to insure this success, however, it is essential
  not to defer the use of the knife until the  disease is  no  longer local,
  and the whole of it  cannot be taken away.   Hence, before determin-
  ing to operate, it is  a rule with surgeons carefully to examine whether
  the disease  has  extended to other parts, especially the glands  in
  the groin.   When  they are  indurated and  enlarged,   many  good
  practitioners decline the operation altogether, the event of  which is
  then always to be regarded as doubtful.  Thus, in one instance,  in
 * Surgical Essays, part i. p. 152.
 t Richter, Anfangsgr. b. vi. p. 183.  G"ttingen, 1802.
 X See case in Hey's Practical Obs. p. 473. edit. 2.
 § Gibson, in Med. Obs. and Inquires, vol iv.
 II Loder, Chirurgisch-Medicinische Beobachtungen, b. i. p. 81.
M Hey's Practical Obs. in Surgery, p. 478. edit. 2. 
442
OPERATIONS.
which the glands of the groin were much tumefied,  Mr. Hey ven-
tured upon the operation, because the swelling of the glands did not
exist before escharotics had been applied to the disease of  the pe-
nis, and consequently it was dubious whether their enlargement was
truly cancerous or not; but the  patient died from  a  relapse.  The
inguinal glands lessened for a time but afterwards increased  consid-
erably:  there  was, however,  never any fresh  ulceration.*   Some-
times the only part affected, in addition to the penis, will be the in-
teguments covering the ossa  pubis, in which situation a hard tumor
is perceptible.  In one case of this  description operated upon by
Mr.  Hey, a permanent cure  ensued, care having been taken to cut
out the  swelling at the pubes: the wound here remaining for some
time foul; but, on applying to it red precipitate and burnt alum,  it
assumed a better appearance, and afterwards healed.f   When the
cancerous  disease does not extend  beyond the glans, immediately
behind  which the  incision  can  be safely executed, there is no ob-
jection to the method of cutting through the whole of the  penis,
with one stroke of the knife.   However,  in order  to cover the ends
of the  corpora  cavernosa  with  integuments, the plan is sometimes
followed of  first drawing them  towards the pubes, before the incis-
sion  is  made,  or else of merely making at first a circular cut through
the skin, which is next pushed a little way  up towards the pubes,
and the rest of the penis divided in  a  line with the edge of the re-
tracted skin.   This last way of operating, however, is not approved
of by the generality of modern surgeons;  for it is  slower, and more
painful, than a direct incision through the whole organ; it does not
shorten the  cure, and  is liable  to inconveniences.   If, indeed, the
preservation of skin for covering the  end  of the stump were any real
advantage,  the surgeon would always have enough for this purpose by
cutting straight through the  part, because the corpora  cavernosa con-
stantly shrink towards the pubes as soon as they are cut through, and
leave the integuments projecting.  But the truth is, no benefit is de-
rived from the redundance of skin:  in one case, Mr. Hey made an at-
tempt to heal  the wound by the first intention, and, with that view,
brought the  integuments  over the  divided corpora cavernosa; and
that  he  might make the integuments lie over the  end  of the penis
without puckering, or covering the orifice of the  urethra, he made
a longitudinal  division  of them at the inferior part  of the penis, and
introduced  a small silver cannula into the urethra.   " I was disap-
pointed," says he, "in my design of healing by the first intention;
for the integuments would not adhere to the extremity of the corpo-
ra cavernosa.   These spongy bodies, when divided, do not readily
throw out granulations; but have usually for sometime  an ill-condi-
tioned  appearance."^  An objection to amputation of the penis by
* See Hey's Practical Obs. in Surgery, p. 470. edit. 2.
t Op. cit. p. 463.               X Op. cit. p. 469. 
AMPUTATION  OF THE PENIS.
443
the double incision is, that the superfluous flap of skin, further aug-
mented by the natural retraction of the divided corpora cavernosa,
renders it more difficult to secure  the blood-vessels, which become
concealed under it, and are disposed to  retract, on  account of the
loose cellular substance  with which they are surrounded.  At all
events, if the  surgeon choose to save the skin, let him not prolong the
patient's  sufferings by two formal distinct incisions, with an interme-
diate dissection of the integuments from the corpora cavernosa, as it
will be quite sufficient to draw the skin a little way towards the pubes,
when the amputation may be completed with a single stroke of the
knife.
   When the  penis is to  be amputated near the symphysis of the
pubes, less skin should  be taken  away, because the  retraction of
the corpora cavernosa is in proportion to the length of the  portion
of them  left.   Sometimes, however,  their extremities  in this situa-
tion  lie so deeply concealed within the integuments, that the  sur-
geon cannot discover, nor take  up, the bleeding vessels.   In  one
example, says Richter, the arteries shrunk so far under the  pubes,
that they lay two inches within the extremity of the skin.*
   As the hemorrhage after amputation of the penis  is  profuse, and
often cannot be effectually restrained, unless  the larger arteries are
secured with  ligatures, it is a matter of great importance to perform
the operation in such a manner as will enable the surgeon to get at
these vessels with the least difficulty; and hence the utility of aban-
doning the  project  of  saving  skin  for the purpose  of covering
the stump.   Without this precaution,  as a modern  surgeon  has
remarked, while the tendinous business of getting the ends  of the cor-
pora cavernosa from beneath the integuments by which they are con-
cealed, and of finding out the arteries,  is going on, the continued
bleeding   often reduces the patient to the lowest state  of weak-
ness, and the practitioner is at  last compelled to have recourse to
compression, styptic applications,  cold water, or the cautery.   Nor
are these means always  capable of stopping the hemorrhage in time,
or in a permanent manner, the  effusion of blood ceasing only for a
little while; and their irritation  always increases the inflammation of
the stump, and protracts the cure.   Thus, in one  example, where
the hemorrhage  was considerable, the  blood flowing not only from
many conspicuous arteries, but oozing largely from the divided cor-
pora cavernosa, Mr. Hey took up one artery on the dorsum penis
and  one  in each corpus  cavernosum.  The bleeding, which  still
continued, seemed then to be a general oozing from the  wound, on
which  account he applied sponge to it.   But this would not do; for,
about  an hour after the patient  had been put  to  bed, the bleeding
burst out again, and Mr. Hey was therefore obliged to remove the
dressings, and take up three other arteries.   A fourth vessel, which
* Anfangsgr. b. vi. pp. 185, 186. 
444
OPERATIONS.
passed near the urethra, bled  a little;  but,  as  its extremity could
not be clearly seen, a piece of sponge  was laid  upon it.   On  the
third day, a fresh hemorrhage came on, which made it necessary to
remove the last portion of  sponge, and take  up  the vessel under it,
which now bled freely.*  In  another  example,  Siebold could  tie
only one artery, the others having shrunk so deeply, that they could
not be discovered.  After the  patient had fainted,  the bleeding
stopped; but it broke out  again, and was at length checked with
cold water.   The weakness from loss  of blood  was such, howev-
er, that the patient was a month  in recovering his strength, and his
feet continued for  some time cedematous.f   Joerdens saw a case in
which the stump became retracted under the pubes,  and a violent
hemorrhage ensued, which nearly proved  fatal,  and could hardly
be restrained in half an hour, by tying three  arteries, and having re-
course  to  compression,  and  a  styptic  liquor.:}:  B.  Bell was
still more unfortunate,  for he ventured to trust entirely  to  pressure,
without taking  up  any  of  the  vessels; the  consequence  was, that
so copious a bleeding  came on, a  few hours after  the operation,
that the patient lost his life.§   In another case, the surface of the
stump, which had  been treated with compression and styptics, was
long ill-conditioned, pale, and indurated ; nor did  the wound begin
to diminish at all before the thirteenth day||,  in which space of time,
another instance, treated differently, had completely healed.H
   Certain cases prove, that the corpora cavernosa sometimes have
a great tendency to retract,  when cut through  towards the pubes;
and that even  when care has been  taken to amputate more of the
integuments  than of them,  their extremities  will  still frequently be
deeply concealed,  and the taking  up  of the arteries  be  difficult.
Nor will the  plan of encircling  the stump with a tight piece of tape
here avail in obviating  the  disadvantage of the retraction of the cor-
pora cavernosa, and the immediate danger  of hemorrhage,  as the
stump  is short, and the band therefore  liable to  slip off.   Even if
the band could be  fixed tightly on the part,  it would only  serve as
a temporary  means  of stopping the bleeding, which would  be re-
newed immediately the band  was loosened  for  the purpose of ena-
bling the operator to see the points  from which  the blood issued.**
This plan, however, has been adopted with  success in Germany,ff
and Mr. Hey assures  us, that, in one  of his cases, he  found great
advantage from having  applied some tape round the sound part, as he
* See Hey's Practical Obs. in Surgery, p. 465. edit. 2,
t Chir. Tagebuch, p. 52.
X Loder's Journal, 3 b. 1 st.
§ Syst. of Surgery, vol. i.
II Schmalz, in Loder's Journ.  1 b. s. 622.
IT See Schreger's Chirurgische Versuche, b. i. p. 143.
** Ibid. p. 247.
tt Ollenroths, in Hufeland'g Journ. 3 b. s. 56. 
AMPUTATION  OF THE  PENIS.
445
was thereby not only enabled to divide the integuments more easily
and correctly, but was furnished with  an useful kind of tourniquet,
which kept the divided vessels from bleeding till he was prepared to
take them  up  with the tenaculum and ligature.*
   Were a case to present itself,  in which the mouths of the arte-
ries could  not  be taken up, the practitioner would  be compelled to
resort to means,  which experience proves to have occasionally suc-
ceeded under similar circumstances; as, for instance, compressionf,
with agaric,  sponge, or lint dipped in powder of gum arabic, ice-
cold watery, and the actual cautery§,  a circular band, strip of plas-
ter or tourniquet, &c.   The uncertainty of all these methods, how-
ever, is generally acknowledged.
   The  arteries requiring ligatures, are those of the dorsum and cor-
pora cavernosa.
   In order to prevent a closure of the urethra, as well as to enable
the patient to  make water easily, and keep the urine from coming
into contact with the wound, some  surgeons, as soon as  the opera-
tion is  finished, introduce a short silver cannula, or an ordinary  ca-
theter  into that canal.   If the short cannula be  chosen,  it must be
made with little rings, so that it may be conveniently fastened in its
situation.   Were the  amputation about  to  be  done  towards  the
pubes, a silver catheter should be introduced before the operation,
because here the  retraction of  the  parts is such, that the introduc-
tion of  the instrument afterwards might be found  difficult, if not im-
practicable.
   With respect  to the introduction  of any tube, either before or
directly after the  operation in ordinary cases, surgeons are not unan-
imous upon the subject.   I have seen the operation done very well
without it, and the  parts  favorably healed, a bougie having been
passed a little way into the urethra once a day, after the removal of
the dressings, to  hinder the contraction of the orifice of the urethra.
This was Mr. Hey's  practice.
   An elastic  catheter, as creating less irritation, is preferable to a
metallic one.  The irritation  of the wound by  the  urine, and the
necessity of hindering  the orifice of the urethra from closing, will
probably always  lead  many practitioners  to pass a catheter.   The
instrument, however,  should be  large;  for otherwise the urine, by
getting out between  it and the urethra, and wetting the dressings, ir-
ritates  and frets the  wound.  Le Dran mentions a case, in which,
from the neglect to pass a catheter,  the orifice  of the urethra  be-
came impervious, so that the urine could not be discharged.||  Ber-
* Hey's Practical Osb. on Surgery, p. 478.  ed. 2.
t Dolignon, Journ. de Medicine, t. lxxxin.
t Siebold  Chir. Sagebirch, p. 52.
§ Sabatier, Medicine Operatoire, t. ii. p. 306.  Ollenroths, Hufeland's Journ. 3 b.
II Operations in Surgery, p. 158. ed. 2.
 VOL.  II.                      38 
446
OPERATIONS.
trandi cites another case, where, on this account, it became requi-
site to enlarge the orifice-of the  urethra by an incision.

                  PUNCTURING  THE BLADDER.

   The fifth, sixth, and seventh days, from the commencement of the
total obstruction,  are those on which the urine is likely  to escape
from the bladder, hence, Sir Charles  Bell recommends an outlet
for it to be  made on the fourth day.*
   Although I am an advocate for not  delaying the operation, after
milder methods have decidedly  failed,  I believe that these will al-
most always prove successful in  skilful hands,  and that  it may gen-
erally be avoided.   At the present day, the necessity for paracente-
sis is frequently superseded by the excellent  practice of making an
opening in the membranous portion of the urethra, which, in cases of
bad  stricture,  is generally dilated behind the obstructed part of  the
canal.
   The  bladder may be punctured,  either in  the perineum,  above
the os pubis, or through the rectum.  Of the  first operation I shall
say nothing, for it is now generally relinquished.   I allude to the old
method of  opening the bladder with a trocar,  between its neck and
the insertion of the  ureter; because  cases frequently present them-
selves, in which letting out the urine by an incision in the perineum
is  much more  advisable, than either puncturing the bladder from the
rectum, or above the pubes.  But the operation to which I refer, is
not a hazardous thrust of a trocar at a point  between  the neck of
the bladder and the insertion of the ureter, a point which can never
be hit with certainty; but a simple incision in  the dilated membran-
ous portion of  the urethra.   In  retentions of  urine from strictures,
not admitting  relief  by other means,   Sir Astley  Cooper prefers
making an opening in the urethra to  the practice of puncturing  the
bladder,  which, in male subjects, he considers hardly ever necessa-
ry.  In them,  retention of  urine mostly arises either from strictures
or disease  of the prostate gland.   Of the  latter,  Sir  Astley  has
never  seen  a case, in which  a  catheter,  of proper form and size,
could not be passed.f   " If," says Sir  Charles  Bell, " a man have
a stricture in the urethra, and the surrounding parts be indurated, so
that there is no immediate hope of removing it by the caustic, or
the bougie; if with  this, there  has occurred a sudden  obstruction,
and the bladder has  risen and lost its action, and there remains no
expectation  of  spontaneous relief,  or of ease  from lesser remedies,
then I apprehend  it is better  to open the urethra in the  perineum
behind  the  stricture.   And tbis is to be immediately  done, if the
  * Operative Surgery, vol. i. p. 815.
  t Surgical Obs. vol. ii. p. 61. 8vo. Lond. 1818.  If the urethra has already burit,
and effusion taken place, only free external incisions seem necessary. 
PUNCTURE  ABOVE THE PUBES.
447
symptoms   indicate  a rupture  of the  urethra,  and  effusion  of
urine.'"                               ,
  In  University College  Hospital, I had a case, where a diseased
prostate gland rendered the included portion of the urethra perfect-
ly spiral,  so that only a smallish flexible catheter was  capable  of
passing through it;  and at length the  point of  this entered  the sub-
stance of the prostate, a  part of which was  found after  death to be
exceedingly  soft.   Had  it gone a quarter of an inch further, it
would have reached the cavity of the  bladder.   As  the  symptoms
were  urgent, I punctured  the  bladder above the pubes, and drew
off a  considerable  quantity of urine.   The  man did not recover,
and, on examination of the parts after death, it seemed  that a small
quantity  of urine had insinuated itself  between the cannula and sides
of the wound,  and  excited inflammation, which had extended to the
peritoneum.   The  preparation, which is preserved  in the museum
of  University  College,  shows  the track  of the trocar completely
below the reflection of the  peritoneum, and the enlargement of the
prostate  gland  has the peculiarity of being  principally directed  to-
wards the rectum.

                PUNCTURE ABOVE  THE  PUBES.

  Some surgeons make a perpendicular incision, about two inches
in length, through the integuments and  fat covering the lower part
of the linea alba.   Were the bladder thickened and  contracted, or
the patient corpulent, this  preliminary  incision  would  be proper;
but, if the distended bladder can be  plainly felt, the trocar  may  be
at once introduced  through the parietes of the  abdomen  into that
viscus.  A trocar, the diameter of which should  be such  as will
afford a very ready outlet for the urine, and  the curvature form a
segment of a circle  seven inches in  diameter, is to be  passed through
the integuments and linea alba into the bladder.  It is to be held
with its convexity towards the patient's  navel,  and pushed obliquely
downward and  backward in the axis  of that  viscus.   Sir  Astley
Cooper, who uses a straight trocar, directs it  towards the  basis  of
the sacrum, and not so low down as I have mentioned; his reason
is, that the risk of the instrument slipping  between  the  pubes and
the bladder  may  be  avoided.f  At  all events, it is necessary  to
guard against this accident, which has sometimes happened.  A cur-
ved instrument of this kind is much less likely,  than a straight tro-
car, to penetrate the back part of the bladder, and wound  the rec-
tum;  besides,  having this advantage,  that,  when the urine is evac-
uated and the bladder collapses, the cannula will be less  disposed
  * Lectures, vol. ii. p. 315.  It seems that Sir Astley Cooper is entitled to the merit
of first reviving this  forgotten but valuable practice, of which I find traces in the val-
uable work of*L. L. Petit, entitled Traite do Mai. Chir. 3 tomes. 8vo. Paris, 1790.
  t Lectures, voi. ii. p. 309. 
44b
OPERATIONS.
than a straight one to be separated from that organ.   Here we may
discern another reason for making the  puncture immediately  above
the pubes, and not an inch or two higher up, as Sharp and B.  Bel!
recommend: the bladder, which rises up between the peritoneum and
recti muscles, descends again,  when  the urine is discharged,  and,
consequently,  must  be  more  liable to slip from  the cannula, the
higher the puncture  is made.*
   When the operator perceives,  from the  want of resistance, that
the point of the instrument is in the bladder, he is to take hold  of
the cannula, and  push it  further  in, while  he  withdraws  the stilet.
After  the urine has   been discharged, some practitioners, amongst
whom  is Sir Astley Cooper, pass an elastic  catheter, duly shortened,
into the bladder through the cannula, and then  take the latter out.
   Since an elastic catheter does not fill the wound, the urine is dis-
charged, not only through it, but also between  its  outer surface and
the track of the  wound;  so that the chance  of the urine  becoming
diffused in tbe cellular tissue is not  guarded  against, as it is  by al-
lowing the cannula  of the trocar  to remain  in the  wound two  or
three  days,  until inflammation has agglutinated  together the sur-
rounding cellular substance.   In some examples,  the  cannula, after
having been kept a few  days in the  wound, was taken out, and rea-
dily introduced again as occasion  required.f
   Still, I do  not feel authorised to recommend this proceeding; be-
cause  it has happened, that the tube could  not  be  replaced, and the
urine became  confined  agiain, so that a repetition of  the  operation
would have been  absolutely necessary a third time,  had not Schre-
ger succeeded in  procuring an evacuation  through the urethra, by
distending this canal with warm water,  injected with some force into
the passage by means of  a syringe and a cannula, introduced as far
as the stricture would allow4
   Long, straight, silver cannulas have  been  known to form a com-
munication between  the bladder and rectum, in consequence of ul-
ceration, or sloughing, produced by the pressure  of  their points  on
the back part of the bladder.   Mr. Sharp saw this accident§; and
a modern author informs us, that in a  case where  a  common trocar
  * Richerand, Nosographie Chir torn. iii. p. 499.   By the employment of a long
straight trocar, of course the objection here specified might be removed; but the can-
nula of such an instrument has sometimes pressed  against the  opposite side  of the
bladder, and caused an ulcerated opening in it.  In consequence of the bladder hav-
ing slipped away from a short cannula, a repetition of  the puncture beeame necessary
in a case under Professor Schreger.  See Chirurgische Versiiche, b. i. p. 212. Nu-
remberg,  1811.
  t See Bohniiher  Harnverhaltung and Hlasenstich, Leipzig, 1794; Noel in Desault's
Journal de Chirurgie, torn. ii.; Turner in London Med. Journal, vol. xi.; Journal de
M-decine, torn, lxxxiii.
  X Versiiche Chirurgische, b. i. p.] 216. Svo. Nurenberg, 1811.  In cases of reten-
tion of urine, from calculi lodged near the neck of the bladder, Schreger employed the
same artifice with success.  It is this principle of distending the urethra with fluid,
that was once so strongly recommended by Mr.  Arnott in various affections  of that
canal.
  § See a Critical Inquiry into the Present State of Surgery, p.  127. ed. 4. 
PUNCTURE  ABOVE THE PUBES.
449
was used, he dissected the parts; "the bladder  fell  on the  sharp
edge of tbe trocar, this  produced inflammation of the  bladder and
peritoneum, which occasioned the death of the patient."*
   The outlet thus  formed  for the urine is, of course, merely  de-
signed as a temporary one, until the impediment in the natural pas-
sage has been removed.   In one case, seen by Sir Astley Cooper,
where the latter object had not been accomplished, twelve months
after  the  puncture,  a female  catheter  was  yet  worn  in  the
opening, f
   This  operation  has the advantage  of  being  generally done at
a distance from the diseased parts, and  without risk of injuring  any
organs of importance-!   The possibility of the urine getting  out of
the bladder into  the wound, was  exemplified  in  the case under me
in University College  Hospital, and  this notwithstanding the cannula
was not withdrawn and exchanged for an elastic catheter, till the end
of two days from the  period  of the  puncture.   When the cannula
happens  to slip out of the bladder,  it is alleged  that  the  puncture
becomes impervious.   In  fact, this  happened in Schreger's, case,
where the tube slipped out twice; viz. on the evening of the day on
which the bladder was first tapped,  and again on  the third night from
the second performance of the operation; for, after each  displace-
ment of the  cannula,  no  probe could be  passed  into  the blad-
der,  no urine  escaped,  and that  receptacle became enormously
distended  again.   When  a  smallish  trocar  is  used,  this closure
of the puncture by  the mucous coat would  perhaps generally be
likely to take place for a  day or  two after the operation; but, in  a
later  stage, it would be less likely to occur: it did not happen in the
example related by Schreger himself, in which he took out the can-
nula of the trocar on the  thirteenth day, and put in  another§; and
it is therefore not to be regarded  by any means as an invariable con-
sequence of the tube slipping out.  The displacement of the cannu-
la, the possibility of not being able  to get  in another,  and  of  an ex-
travasation of urine, therefore, may still be considered objections  to
this method of operating.  Another disadvantage is, that  the open-
ing is not made in a depending situation, and consequently  the whole
of the urine cannot be readily  discharged.   I once saw Mr. Aber-
nethy attempt this  operation in St. Bartholomew's Hospital;  but the
trocar did  not enter the bladder.  No urine was  discharged, and the
patient died the  following day.
  * See a History of the High Operation for the Stone by Incision above the Pubes,
and an Account of the various Methods of Lithotomy, by J. C. Carpus, p. 176. 8vo.
Lond. 1819.
  t Lectures, vol. ii. p. 310.
  X The preparation in the museum of University College, exhibiting the track of the
trocar, proves that Mr.  King's statement of the peritoneum  being necessarily pierced
twice by the trocar, before the bladder is reached, is a mistake.  See Lithotrity and
Lithotomy compaircd, by Thomas King. 8vo. Lond. 1832. p. 31.
  § Vergiiche Chir. b. i. p. 225.
                           38* 
450                       OPERATIONS.
              PUNCTURE  THOUGH THE RECTUM.

   The patient  is to be put in the posture recommended for lithot-
omy.  The patient is to make pressure on the abdomen, just above
the pubes, in order to render  the prominence  of  the  bladder more
distinct to the surgeon's finger in  the rectum.   A curved  trocar,
with the point of its stilette draw within the cannula, is  to be intro-
duced with the right hand, and under the guidance of the left fore-
finger first passed into the  rectum so as to feel the base, or posterior
part, of the prostate gland.  It should  be kept exactly in the cen-
tral line of the front of the rectum, and, as soon as the end of the
cannula is beyond the prostate gland, its handle should be depress-
ed, and the stilette  pushed into  the bladder, through the  anterior
part of the intestine, as nearly as possible in the middle of  a small
triangular space, bounded  at  the sides by  the vasa  deferentia and
vesicula? seminales,  which  converge to the prostate gland, and be-
hind by the line at which the peritoneum is reflected from the blad-
der to the rectum.  If the puncture be made  in  the centre  of this
space, just beyond the  base of the  prostate gland, while the  bladder
is distended, there will be  no danger of wounding  the vasa deferen-
tia, vesicula? seminales, or peritoneum*
   After the urine has  been discharged, the cannula should  be fixed
in its place, of two pieces of tape passed  through  its rings,  and
fastened  in front and behind  to a bandage round the waist.   It is to
be closed with a stopper, which may  be taken out as occasion re-
quires, and may be further secured with a compress and T bandage.
As soon  as the obstruction in the urethra is removed, the  cannula
is to be withdrawn, or in some cases it may be withdrawn in from twelve
to twenty-four hours, and  the urine  allowed to pass through  the new
openining.   The reason in  favor  of this plan is, to get rid of  the
 annoyance of the cannula in the  rectum: the  reasons  against  it
 are, the possibility  of the opening closing prematurely, and of the
 urine causing inflammation, ulceration, and sloughing of the rectum.
 Sir Astley Cooper objects to this operation, on the ground,  that the
 irritation  of the urine is likely to bring on inflammation and disease
 of the rectum, as happened  in a case  under Dr. Cheston.   When
 the prostate gland is enlarged, it is manifestly  inapplicable.

                           LITHOTOMY.

    The generality of vesical calculi are originally formed in the kid-
 ney, whence they descend  into the bladder through the ureter, but
 are either too large to be  voided through the urethra, or are prevent-
  X Sir Astloy Cooper, Lectures, vol. ii. p. 311.  Also J. F. Malgaigne, Manuel de
Med. Operatoire, p. 682. 12mo. Paris, 1834. 
LITHOTOMY.
451
ed from entering the latter passage by the projection of an enlarged
prostate gland.*   When, however, any foreign body remains in the
bladder,  it soon becomes incrusted with other matter deposited  on
it from the urine, and thus forms the nucleus of the calculus.
   The composition of calculi  is various:—1.  Lithic acid.   2. Ox-
alate of lime, or mulberry calculi, which are of a dark color, very
hard, and have a regular surface.   3.  Triple phosphate of ammonia
and magnesia.   4. Phosphate of lime.  Calculi, composed entire-
ly of this, are rarely met with  in the bladder;  and when  they are,
the researches of  Dr. Prout tend to prove, that they are derived,
not from the urine, but from the secretions of the bladder itself.   5.
Calculi,  consisting partly of the  triple phosphate of  ammonia and
magnesia,  and  partly of the phosphate of lime, blended  together.
6. Lithate of ammonia,  seldom met  with  except in children.   7.
Lithate of soda, exceedingly rare.  8. Cystic oxide.   9.  Carbo-
nate of lime.   A calculus, composed altogether of this  substance,
is very rare, though a small quantity of it  is  often commixed with
other matters.   10. Xanthic  oxide.  11.  Fibrous calculus.  The
two latter, first described  by Dr. Marcet,  are uncommon.f  Chil-
dren and elderly persons are well known to be more liable to calcu-
 li, than persons of the middle  periods of life.   In the poor classes,
 children are afflicted with remarkable frequency;  but, in the higher,
the disorder is more common in old than young subjects.
   The museum of University College affords  abundant evidence of
 the great liability of patients with diseased prostate glands to the
formation  of  calculi.   Their  bladders can never   be  completely
 emptied; and, as  Sir  Benjamin Brodie correctly remarks, if a small
 calculus from the  kidney find  its way into the  bladder,  it cannot
 escape by the urethra, and remains and increases.  Lithic acid, and
particles of phosphate of lime, or any thing else which can act as a
 nucleus, becomes  ako,  under  these circumstances, the  foundation
 of a stone in the  bladder.  In cases of diseased  prostate  gland,
 the mucous membrane of the bladder sometimes becomes inflamed,
 and the mucus secreted  by it  deposits phosphate of lime  in small
 masses,  and each of these becomes the nucleus of a  calculus; but
 such calculi may unite and form larger ones.
   While a stone in the  bladder  is of trivi.il size, smooth, and not
 angular in its figure,  little inconvenience  may result from it; but,
 when it  is above a certain weight, rough,  and  of irregular figure, it
 always produces more or less suffering.  The symptoms, however,
 seem to  be influenced  by the quality of  the  urine, which may be
 unusually  acid, or  alkaline, depositing the triple phosphate.  As
 Sir Benjamin  Brodie has remarked,  in either  of these cases it will
  * Sir Benjamin  Brodie on Diseaies of the  Urinary Organs, ed. 2. p. 209  8vo.
Lond. 1835.
  t On this subject, consult  the writings of Brande, Marcet, Prout, Henry, Yelloly,
and Brodie. 
452
OPERATIONS.
be too^stimulating, and the  symptoms produced  by the stone will
be  aggravated.   The state  of  the  bladder itself also makes con-
siderable difference, nothing augmenting the severity of the  symp-
toms so much as inflammation of the mucous membrane.   While
this exits, a small calculus will cause infinitely greater distress than
a large one  under ordinary circumstances.*   Another reason,  as-
signed by him for the increased severity of the symptoms, when  the
urine is alkaline, is, that  the state  of  the general  health, which
causes alkaline urine to be secreted, is attended with a morbid sen-
sibility of the nervous system in  general.  A dull, annoying pain is
felt at the extremity of the penis, and hence, children are continual-
ly pulling the prepuce, and it often becomes remarkably lengthened.
A sense of  weight  is  experienced in the perinaeum; there is a fre-
quent desire to make water,  and sometimes uneasiness about  the
rectum, tenesmus, or, in children,  even prolapsus ani.   In  conse-
quence of a small  stone falling  on the inner orifice of the urethra,
the stream of urine  is apt to be suddenly stopped,  although the blad-
der yet  contains a considerable quantity.   The evacuation is at-
tended with  pain, especially towards the  conclusion of it,  when  the
inner surface of the bladder embraces, as it were, the foreign body.
   The urine contains a good  deal of mucus, which forms a sedi-
ment, and, when the patient takes exercise, sometimes blood.   In
an advanced stage,  ulceration of  the inner coat of  the bladder  oc-
curs, and then the urine has an offensive smell, becoming putrid and
ammoniacal, and depositing a mixture of mucus and  pus, more or
less blended with blood.   After  a time, the symptoms of disease of
the bladder  and kidneys are added to those of  stone; the patient
loses  his appetite, becomes hectic, and the urine albuminous.   Fre-
quently, the patient,  if not relieved  by operation, falls a victim to
inflammation of the bladder, already much diseased.   Occasionally,
large  abscesses form in the cellular tissue of the pelvis.   Together
with these symptoms, there may  be numbness in the thighs, and the
testicles are often painful and retracted.  In the case of  a gentle-
man lately attended by Mr. Bransby Cooper, Dr.  Rigby, and my-
self, and who died of stone, one kidney was much enlarged, and
the left ureter,  whose communication below, with the bladder was
obliterated,  was as  wide and capacious as  one of tbe  small intes-
tines.
   An enlarged prostate gland is  attended  with symptoms more or
less similar  to those of stone; but, with this difference, that riding
in a coach,  or  on  horseback, does not augment the grievances,
when the prostate gland  is  affected; while, in cases  of  calculi, it
does so  in  an intolerable degree, bringing on likewise a discharge
of bloody urine.   The  fits of pain from a calculus in the bladder
* Sir Benjamin Brodie on Diseases of the Urinary Organs, p. 225. ed. 2. 
SOUNDING FOR THE STONE.
453
generally  come on at intervals; whereas  the  pain  from a diseased
prostate gland is neither so unequal, nor so acute.
  As the  iymptoms of  stone in the bladder  bear a  strong resem-
blance to  those of several other affections, surgeons never ponounce
a decided opinion on the nature of the  disease, until they have in-
troduced  a metallic instrument (called a sound)  into the bladder,
and actually touched the stone itself.  But a judicious practitioner,
who may  not be able to feel the  calculus, will be cautious not to
say positively, that there  is  no stone  in the bladder; for the next
time the patient is sounded,  its position may be  different, and it
may be distinctly hit with the instrument.  In relation to this part
of the subject, I  admire the candor of Sir  Astley  Cooper, when
he says: " I have myself sounded, and not detected a stone at one
time, which I have afterwards felt.  I have  sounded, and not dis-
covered a stone,  which another surgeon has  afterwards perceived.
I cut a patient, and extracted thirty-seven stones from his bladder,
who had been sounded, and  declared not  to have a stone."*

        OF SOUNDING,  OR SEARCHING FOR THE STONE.

   The instrument, expressly calculated for this purpose is denomi-
inated a sound, which is not hollow like  a catheter, but solid,  and
made of the best steel.    As a stone is  generally carried by its own
weight to the lowest part of the bladder, the sound is less curved,
and somewhat longer than a  catheter, in order that it may reach be-
hind and  below the  neck of  that  viscus.  Being only a particular
kind of probe, the  chief use of  which is  to convey  information
through the medium of the  organ of touch,  its  handle should  be
highly polished, so that as may points of it may be in contact with
the fingers as possible.    The mode of introducing it is the same as
that of passing a  silver catheter.
   When  its extremity is  in  the  bladder, it is first  to  be  inclined
downwards, for the purpose of ascertaining whether the stone oc-
cupies its most frequent situation, beneath the extremity of the in-
strument.  If  the calculus cannot be felt in  this direction, the end
of the sound may be gently  turned, first  to one  side and then the
other; and, in the event of the  calculus not being now  touched,
the handle of the instrument  is to be depressed,  and its extremity
inclined upwards and forwards, in order to learn whether the foreign
body may not  lie more towards the fundus of the  bladder.   Fre-
quently,  the stone cannot be felt before the  whole of the urine has
been voided,  and  the  bladder is  contracted; and  sometimes the
sound cannot be made  to strike the calculus, unless this  body  be
first raised up by a finger passed into the rectum, in doing which
* Sir Astley Cooper's Lectures, vol. ii.  p. 248. 
454
OPERATIONS.
the surgeon may  occasionally feel the stone, if it be large, through
the intervening coats of the bowel and bladder.   As, however, this
method is seldom  requisite,  except when the  calculus is smallish,
the practitioner must  not always  expect to feel it with his finger
through the bowel; nor is it a matter of  any practical  importance,
because the information thus obtained is more liable to be fallacious,
than what the sound  affords, and if the  stone cannot be felt  with
this instrument, any kind of feel, communicated  to the finger with-
in the rectum, would  not warrant the making  an  incision  into the
bladder.
   When the stone is  smallish, and lies on one side of the neck of
the bladder, it may not admit of being readily  hit  with  the sound.
Also, when, from  repeated attacks of inflammation, hardened folds,
or, from other causes, distinct cysts  have been formed within the
bladder, the calculus sometimes lies within a depression, or cavity,
and cannot be felt  with the instrument.   Under such circumstances,
before the sound  is  introduced, the  patient should hold  his wa-
ter, until the bladder is quite full, and, if  possible,  until it is so dis-
tended  as  to efface,  or diminish,  its  preternatural  excavations
Then the  patient should stand up, and make water, with his body
inclined forwards,  whereby the calculus will be carried towards the
neck  of the bladder, and admit  of being struck  with  the instru-
ment.*   I have known several cases, where the calculus could be
touched with a silver  catheter, but not with a sound.   Instruments
of different curvatures and lengths should be tried, when the symp-
toms are strongly marked, yet the calculus cannot  be felt.   When-
ever the surgeon cannot readily touch  the stone, the  patient is  to
be sounded in different attitudes.
   In sounding, how possible it, is to  mistake a thickened, indurated
bladder for a stone in  that organ, may be well conceived, when  it
is considered that  Cheselden, with all his judgment and experience,
actually cut no less than three patients, none of whom had any
stone in the bladder at the  time of the'operation.  On the other
hand, the  case of  the celebrated French surgeon, La Peyronie, ex-
emplifies most convincingly,  the possibility of failing to  discover a
stone even of considerable size, though  the  sound  be repeatedly
passed.
   There are three methods of treating calculous patients generally
considered  by writers;  one is that of  attempting to dissolve the
stone; a second,  that of palliating  the  symptoms; and the other
aims at the removal of the calculus  fro n  the bladder  by a surgical
operation.   In women, the  latter object  may  often  be  performed
by dilating the meatus urinarius, without using any cutting instru-
ment!;  Dut>  in  the male sex,  the great  length, narrow diameter,
* Richter, Anfangsgr. b. vii p. 103.
t Notwithstanding the many respectable advocates for this practice, some men of 
SOUNDING FOR  THE STONE
455
winding course, and considerable  irritability,  of  the  urethra, make
the extraction of calculi through  it, and even the getting hold of
them in the bladder  with any instrument introduced  through the
passage, more  difficult.   However, the success  which  Sir  Astley
Cooper, Sir Benjamin Brodie, and  others have had  in extracting
calculi of moderate size from the bladder with the urethral forceps
constructed by Messrs. Weiss, and the efficiency with which litho-
trity is  frequently resorted to for reducing larger stones to small
particles, capable of  discharge with  tbe  urine,  have already made
due impression on every  practitioner, desiious of lessening the fre-
quency of one of the most painful and fatal operations in surgery.
At the  same time, when  the  calculus is above a  certain size, or the
bladder is  diseased, and   incapable of  bearing the irritation  of the
fragments, lithotrity is likely  to prove even more fatal  than  lithoto-
my.  When the kidneys are diseased,  the chances of recovery af-
ter either operation must be  hopeless.
   Though the calculus may  have been felt  with a sound,  at  some
 period or another previously to the time fixed  upon for the operation,
it is an  established maxim in surgery,  never to  perform lithotomy,
 unless the stone can be plainly struck with a sound,  or staff,  imme-
 diately before the operation.   A man may have a stone in the blad-
 der to-day, and  the surgeon  may strike  it  so manifestly with the
 sound,  as to make the circumstance perceptible to the ears of the
 by-standers, as well as to his own fingers; but to-morrow, the stone
 may protrude  between the fasciculi of the  muscular fibres of the
 bladder, carrying along with  it a  pouch, formed by the lining of this
 viscus, and, in this circumstance, the stone is no longer in the cavi-
 ty of the bladder;  consequently,  it can neither  be felt with the
 sound, nor extracted  by  the  operation  of lithotomy.
    An interesting case is  recorded  by Sir Benjamin Brodie, where
 a calculus was included in a  sac, composed of the  muscular, as well
 as the  mucous  coat,  and  used to  create severe  pain whenever it
 passed, as it sometimes did,  out .of  the sac  into the  cavity of the
 bladder.
    In many instances, there is only a single calculus in the bladder;
 in others, several;  and sometimes thirty or forty.   When their num-
 ber is greater  than  one,  their rubbing  against each  other generally
 gives them a smooth  surface.
considerable eminence object to it, as being more tedious and painful, and more like-
ly to be followed by an incontinence of urine, than the use of a cutting instrument.
Of this sentiment is the experienced Klein, who has tried both methods, and in 1816
had cut for the stone 79 patients. See Practische Ansichten der Bedeutendsten
Chirurgischen Operationen, auf eigene Erfahrungen gegrundet von D. C. Klein,  p.
21.  2 tes Heft, 4to.  Stuttgart, 1816. 
456
OPERATIONS.
                           OPERATION.

   As one of the principal  dangers of lithotomy is inflammation of
the bladder and peritoneum, I think the common principles of sur-
gery teach us, that it must  be a  matter of prudence  to  remove, if
possible,  before-hand, any state  of the  constitution known to pro-
mote the  access of inflammation.   A low regimen, for a few days
previously to the  operation, and a  dose  or two  of  mild  aperient
medicine,are generally advisable.   The rectum should be emptied
with a clyster a few hours before the patient is cut, as its distension
would expose it to injury.
   Many surgeons  deem it advantageous to let the bladder be some-
what distended with urine when  the patient is cut; and  hence, he
is usually directed to avoid making water for an hour or two before
the operation.   This advice I  consider well  founded, particularly
when a gorget is to be thrust into  the bladder, which, in an empty
state, must be more liable to be wounded at its posterior part; but,
in operating with a knife, whether  this organ contain  urine or not,
cannot  be a matter of importance, unless  the  escape  of  the  urine,
when the  instrument enters the bladder, is to be considered as use-
ful information.   Klein, who  is  in  the  habit  of using  a common
scalpel, never  gives himself any concern about the bladder being
empty or not.*
   The patient should be  placed  upon nearly a flat surface, where it
is much easier to  introduce an  instrument  in  the direction  of the
axis of the pelvis, than when the table slopes  considerably, which
would also oblige the operator to kneel down to gain the advantages
which he  fully has sitting down at his ease,  before a table that has
nearly a straight horizontal surface.f  The table should  be high
enough to bring the perineum on a level with the surgeon's breast.
The buttocks should be somewhat more raised than the abdomen;
the patient lie upon pillows conveniently placed; and the nates pro-
ject rather beyond the edge of the table.!
   In arranging the posture of the patient, the  chief objects to be
attended to are, first, to let  the  buttocks be exactly even;  to take
care that  neither of the assistants draws the thigh too much towards
his own side; and that the parts, situated between the raphe of the
perineum  and the  ascending ramus of the  ischium be stretched,  in
which condition the requisite incisions can be performed with more
facility. §
   A staff is then to be introduced  into the  bladder.  Two  strong
  * Chirurgische Bemerkungen, p. 26.
  t Ibid. p. 23.
  X C. J. M. Langenbeck uber eine einfache und sichere Methode des Steinschnittei
oait einer Vorrede von Dr. J. B. Siebold, p. 44.  Wurzburg, 1802.
  § Langenbeck, op. cit. 
LITHOTOMY.
457
garters or ligatures,  each about two yards long, are then to be dou-
bled, and placed  by means of a noose round the  patient's wrists,
who is next to take  hold of  the outside of his feet  with  his hands,
the fingers being applied to  the soles.   The  two ends of the liga-
ture are  then to be carried in opposite directions  round the  ankle,
over the back of the hand, and under ihe foot, where  they may be
tied in a bow.   The hands and feet being thus securely  connected
together, the knees  and feet are to be supported, kept steady, and
held apart by the assistants.
   The staff should be introduced  before the patient's hands  and
feet are  bound  together;   first,   because,  if the calculus can-
not  be  felt with thfs  instrument  (which  being  now used for the
sound, saves the patient  the pain of a double introduction through
the urethra), it will  not be necessary to tie up the patient  at all, as
the operation  must not be attempted; secondly, because, while the
patient  is unbound, the instrument is  more easy  of  introduction,
and in searching for the  stone, a change of  posture is  often  neces-
sary.
   A curved director, the groove of which serves to guide a cutting
instrument into tbe bladder, is an  exact definition of a staff.  It is
shaped like a sound,  or catheter,  so that it may  pass  through the
whole of the  urethra.  Its  handle, instead  of being  smooth,  like
that of a sound, should be rough, in order that it  may  be held with
greater steadiness.  The  groove,   which is  to be  deep  and wide,
should terminate in  a short conical beak.   The diameter of the
 staff should  be as great, as can  easily be passed into the urethra;
 for, the  larger the size of the staff, the  more easily can it be felt in
the1 perineum, the more distended  the membranous part of the ure-
thra becomes, and the more regular the incision in it is likely to be
 made.   That the instrument is fairly in the bladder, may be  known
by its handle sinking  towards  the ground, without  the least imped-

    In the first stage of the operation, the staff is  to  be held by an
 assistant, who also  raises the scrotum with  his left hand, and gives
 the surgeon a complete  view of the perineum.  Some  operators are
 anxious, that the convexity of the  instrument should project distinct-
 ly in the perineum, for  which purpose,  the assistant  is desired to
 hold the handle perpendicularly to the  patient's  trunk, and to pro-
 pel the  whole staff  gently towards the part,  where  the first incision
 is to be made into it.  The manner of  holding the staff, in tbe first
 sta-e of the operation, differs, however, with different operators.
 Sir&Benjamin Brodie and many other surgeons prefer that position
 of it in which it is  nearly perpendicular, with the handle a little in-
 clided towards  the  patient's right  groin, so  as to cause the convex-
 ity  of the instrument to  project slightly on the left side of the pen.
    VOL.  II-                  39 
458
OPERATIONS.
neum.*   Scarpa, Dupuytren,  Lystonf, SymeJ, and others, deem it
better to raise the concavity of the staff towards the arch of the pubes,
and  to hold it firmly there, the  handle being exactly perpendicular,
without any inclination of it to the right or left, or any projection of the
instrument in the perineum. After the presenceandprobahlesizeof the
stone had been ascertained with the staff,  Dupuytren  gave to the
latter a vertical direction, so that the  straight part of the instrument
formed a right angle with the axis of the body, while the curve was
kept somewhat elevated  towards the  symphysis  pubis, rather than
pressed downwards and backwards upon the rectum.   A steady as-
sistant retained it  precisely in  this  position.   " Its curved part is
drawn  up closely under the arch of the pubes in order to prevent its
pressing too much downwards  upon the rectum."   However, some
of the advocates for the latter plan make use of a  staff, the groove
of which, as  it  passes towards  the bladder, runs  in the interval be-
tween  the convexity,  and right  side  of the instrument.   " The
groove being placed upon the side of  the staff enables the surgeon
to cut  into it more easily, and also to give that direction to his knife,
by which  he divides the neck of the  bladder and  the prostate on
the left side."§
   The patient  having been secured  in  the proper position,  and the
staff held  perpendicularly, with the  groove directed a little towards
the left side  of the perineum,  the surgeon traces with his left fore-
finger the descending ramus of the pubes,  and the ascending ramus
and the tuberosity of the  ischium, and then  mr.kes his  first incision
through the  integuments  and  superficial  fascia,  beginning  it in an
adult an inch and  a quarter above the  anus, close to the left side of
the raphe, and  carrying it obliquely downwards and  outwards, about
three inches, to a point, situated one third from the  inner side of the
tuberosity of the  ischium, and  two thirds  from  the  anus.[[   The
knife should  be pushed in fully one inch deep; and, as it is carried
downwards to the termination of the incision,  it is to  be gradually
withdrawn from its deep position,  in  order to  avoid  the rectum.IT
By extending the cut  in  this manner  to a point nearer the ischium
than the anus, the edge of the knife, in the future steps of the ope-
ration, can be more conveniently and surely directed away from the
rectum.   In a  full-grown person,  the beginning of the first incision
should never be more than  about an inch and a  quarter above the
anus, because laying open a greater extent of the urethra,  towards
  * On diseases of the Urinary Organs, p. 271. ed. 2.i  Sur une Manure Nouvelle
de pratiquer 1' Operation de la Pierre, fol. Paris, 1836.
  t Liston's Elements, part iii. p 197.          X Syme's Principles, p. 511.
  § See Morton on the Surgical Anatomy of the Perinaeum, p. 72.
  || See a paper on Lithotomy, in Med. Chir. Trans, vol. viii.; and E. Stanley, on the
Lateral Operation, p. 5.  4to. Lond. 1829.
  IT Sir Charles Bell's Great Operations of Surgery, p. 117. Th. Morton, op. cit. p.
7?. 
LITHOTOMY.
459
the bulb, will  have no more effect in facilitating  the extraction of
the stone from the bladder, than if the whole of the urethra were
divided.   Besides, when the external incision is made too high up,
and the internal  completed, the former is  likely to be  placed too
high in relation to the opening in the bladder.  The consequences
are, that the same impediment to the extraction  of the calculus  is
experienced, as if the wound were too small; and  the  urine, not
finding so ready  an outlet from the bladder after the operation, is
more likely to become effused.
   The first incision is made through the  integuments, fat, and su-
perficial fascia.   The second divides the  lower fibres of the accele-
rator urinae, the transverse muscle and artery of  the perineum, and
a part of the levator ani  and deep  perineal fascia.   Then, the sur-
geon feels for the staff in the upper part of the wound  with bis left fore-
finger, and, cutting into  its groove, opens the membranous  part of
the urethra.   In accomplishing  these objects, the  principal  things
for avoidance are cutting the bulb of the urethra,   endangering the
great pudic artery, wounding the rectum,  and opening the urethra
too high up.  Next,  supposing the operation to be finished with a
scalpel that has no beak,  the point of it is to be raised, the handle de-
pressed, and its  edge directed  downwards and  outwards towards
the lower angle of the wound.   The point having now been secure-
ly placed in the groove of the staff,  with the back of the blade turn-
ed upwards and inwards, the rest of the membranous portion of the
urethra,  and  the left side  of  the  prostate gland, are  to  be  cut
through by pushing the,knife inwards, along the groove of the staff,
guided, as  it were,  and  followed by  the left  forefinger into  the
bladder.
   In dissecting down  to the membranous  part of the urethra,  and
in laying it open, as well as in cutting deeply towards the  prostate
gland, the surgeon should never direct the edge of the knife straight
downwards, because he  would thus  cut the lower  part  of the rec-
tum; neither should he cut horizontally,  for the  great  pudic artery
would be endangered.   While the surgeon is completing  the deep-
er incisions, he should endervor the depress the rectum towards the
right side with his left forefinger.'
    If a beaked knife, or a gorget, is to be employed for the division
of the prostate gland,  the  operator, as  soon as the membranous
 part of the urethra has been  laid open,  is to  place the  beak of
the knife or gorget in the groove of the staff, and,  being sure  that
this is effected, he is to  take hold of the  handle of the staff himself;
 bring it forwards, so as  to elevate the further portion of  its  groove
away from the rectum;  and then push the beak of  the knife or gor-
 get along the  groove  into the bladder.  The gorget divides the
* See Morton's Surgical Anatomy of the Perinaeum, p. 73. 
460
OPERATIONS.
prostate gland as it enters, and so will a knife of broad construction;
but when  a narrow beaked scalpel  is used, the division is made as
the instrument  is  withdrawn.  Whatever instrument is employed,
its edge is to be directed  downwards and outwards.
  When lithotomy is performed  with a knife, it seems to me, that
there  is great advantage in letting an assistant hold the staff through-
out the operation, because the operator's left  forefinger  is then of
considerable use to him as he is making the requisite incisions.  As
a staff nearly straight, like that  of Mr.  Aston Key, will admit of
being readily introduced through the whole of  the urethra, and it is
much easier to pass a gorget, or knife, along a straight groove than
a convex  one, it may be asked, why such a staff is not generally
preferred?  One objection made to it is, that  it occupies the sur-
geon's left hand, while the section is made, instead  of leaving it at
liberty to  press  aside the  rectum, and ascertain  when the  incision
has been  carried far  enough.   "In  children," says  Mr. Syme,
" where the prostate is easily divided, and where, from the necessa-
rily small  size of the instrument that is introduced, the difficulty at-
tending a  curved  direction of the  groove is  greatest, the  straight
staff may  be preferable."*
  When a knife is  used in an adult subject,  it should be, with the
handle, about  seven inches long; for the distance  of the  bladder
from the surface of the perineum is sometimes such, that a shorter
instrument would be disadvantageous.  When the prostate gland is
enlarged,  the neck of the bladder is occasionally found to be elevat-
ed  considerably  away  from the perineum, as  is well shown in one
of the plates of Mr.  Stanley's  Treatise  on the Lateral Operation.
" In subjects of an advanced age,"  he  remarks, " a  deep  perin-
eum,  as it is termed, is frequently met with.   This  may be  occa-
sioned either by an unusual  quantity  of fat in the perineum,  or by
an enlarged prostate, or by the dilatation of that part of the rectum
which is contiguous to the prostate and  bladder.   Under either of
these  circumstances, the prostate and bladder become situated high-
er in the pelvis  than  naturally,  and consequently, at a greater dis-
tance from the perineum."   In such cases, Mr. Stanley prefers the
gorget; while,  for a young subject,  a thin  adult, or a case  where
the bladder is closely contracted on the stone,  he expresses a pre-
ference to the knife.
  When the knife or  gorget  has entered the  bladder,—a circum-
stance, indicated by the discharge of urine from the wound, — and
tbe requisite section of the left lobe of the prostate  has been  made,
and the knife or gorget has been withdrawn, the surgeon  is to pass
his left forefinger into the  bladder, along the staff, which  is then to
be removed.   With this finger, the  position of the stone is  ascer-
tained, and  the  forceps directed  accordingly.   The finger  should
* Syme's Principles, p. 511. 
LITHOTOMY.                      461
 bear against the posterior wall of the incision, in order to  prevent
 the  possibility of the forceps being passed between the bladder and
 rectum, which accident  has been known to occur.'   If the surgeon
 cannot immediately feel the stone with his finger, he should then in-
 troduce the forceps, and use this instrument as a probe for detecting
 the  exact place of the calculus.
   Some years ago, the forceps used  to be  made  too thick  and
 clumsy, the inside  of the blades  being  frequently  furnished  with
 teeth, intended to keep the stone from  slipping.  These were ex-
 ceedingly  objectionable;  first, because they often broke the calcu-
 lus  before  it was out of the bladder ; and secondly,  because those
 situated towards the back part of the blades, when the stone hap-
 pened to be grasped there, had the effect of increasing the expan-
 sion of the  instrument so considerably, that it could  not be drawn
 out.f   The teeth have also a  bad effect  in  preventing the  stone,
 when it is grasped  with  its long axis across to the wound, from turn-
 ing, as the forceps are drawn  out, into a better position.   Howev-
 er, though teeth are not to be commended, the inside of the blades
 ought  to be somewhat rough.
   The surgeon should always be provided with several pairs of for-
 ceps, of different sizes.   The handles should be two  thirds of their
 length, and  the blades one third.   The  blades of some ought to be
 flat, for the extraction  of small calculi, or fragments; while  the
 blades  of others  should be  curved, to reach calculi  behind  the
 pubes,  or prostate gland.J
   In attempting to get hold of the stone with the forceps, the ope-
 rator should not  expand the instrument as soon as it has arrived in
 the bladder, without knowing where to direct it; but he should first
 make use of it as a kind  of probe  for ascertaining the  precise situa-
 tion of the stone.   If this  be lodged at the lower part of the blad-
 der, just behind its neck, and be distinctly felt below the blades of
 the forceps, the forceps may be opened immediately over the stone,
 and, after the blades have been depressed a little, they are to be shut.
 Certainly, it is much more scientific  to imitate Cheselden, and use
 the forceps, at first, merely to ascertain the position  of the stone;
 for,  when this is known,  the operator is far more able to grasp the
 extraneous body, in a skilful manner, than if he were to open the
 blades  of the instrument  immediately,  without knowing where they
ou°-ht next  to  be placed,  or when shut.   No man can doubt, that
the injury which the bladder frequently  suffers from reiterated  and
awkward movements of  the forceps, is not an uncommon  cause of
a fatal inflammation of it and the  peritoneum.
* Dupuytren, M<m. sur l'Operation de la Pierre; publ. par.  L. J.  Sanson.  Fol.

t Langenbeck iiber eine einfache und sichere Methode des Steinschnittes, p. 43.
± Sir A. Cooper's Lectures, vol. ii. p. 253.
                        39* 
462
OPERATIONS.
  If the calculus cannot readily  be felt, the forceps should not be
roughly moved about, so  as  to bruise the  bladder, and put the pa-
tient to insufferable agony:  on the contrary, they should  be taken
out, and the forefinger gently introduced,  with which the situation
of the  calculus may  generally  be felt.  If the stone cannot be felt
with the finger, on account of the great depth of the perineum, nor
laid hold of with  the forceps, on account of its lying deeply behind
the prostate gland, in the bas-fond of the bladder*, the stone should
be  raised up, and brought within  the grasp of the forceps by means
of  the left forefinger passed  into the rectum.   When the place
of the  calculus has  been ascertained,  the blades of  the forceps are
to be separated,  and the stone received  between them:  this must
be  done with  great gentleness.  If the extraction  be violently re-
sisted, the stone  should be quitted, the forceps withdrawn, the po-
sition of the stone examined  with the finger, and, if  necessary,  its
long axis made to correspond to  that of the  bladder.  Stones are
often broken, which might be  removed whole, if the surgeon were
less violent, and  more cautious,    The mode of preventing a  cal-
culus  from being broken is,  after it has been  taken  hold of,  to put
4he thumb, or finger, between the handles,  so as to hinder them
from being forcibly  closed.f   The forceps should always be with-
drawn from the bladder in the direction of the external wound, with
a wriggling motion, and  towards  the lower  angle of the  incision,
 because here the space between the  ossa  ischii is greatest.
   When the  stone is so large, that, turned in  any position, it can-
 not be extracted from the wound without violence and laceration,
 the surgeon must either break it  with a strong pair of screw forceps,
 or enlarge the wound  with  a  probe-pointed curved bistoury, intro-
 duced under the guidance of the left forefinger,   To the employ-
 ment  of the knife in this circumstance, I  must express my decided
preference; because breaking the stone  creates a risk of fragments
being  left behind, and, consequently, of  a return of the disorder.
 Some operators, instead of enlarging the wound, so as to divide the
bladder, prefer making a cut through the  opposite side  of the pros-
 tate gland.
    If the stone is broken, as  many of the fragments  are to be taken
 out with forceps as can be readily removed, and the surgeon is then
 to feel with his finger, whether any others still remain.   If they do
 so, gentle attempts must be made to  extract  them with the scoop.
 Lukewarm water is also sometimes injected, with the view of wash-
 ing them out.
    Directly the calculus has been extracted,  it should be examined;
 if  it  be  rough,  it  is a presumptive sign that  it is the  only one; if
 smooth on one side, and rough  on the other, or excavated at any
* See Morton, Op. cit. p. 74.
■f Sir Astley Cooper's Lectures, vol. ii. pp. 254—262L. 
DANGERS OF  GORGETS.
463
surface,  there  may  be other stones.  But,  in every  instance, the
forefinger should be introduced, to  obtain decisive information  on
this point; for  it would be unpardonable  to put the patient to bed
while another calculus remains.

                     DANGERS  OF  GORGETS.

   The disastrous accidents, which occasionally result from the em-
ployment of gorgets, have induced many judicious surgeons to pre-
fer finishing the operation with a knife, or, at all  events, some kind
of cutting instrument, not suddenly thrust into  the bladder,  like a
common gorget, with a risk of slipping away from  the staff, and do-
ing the most fatal mischief.   From  mistakes and  unskilfulness  in
this part of the operation,  I have  known of two cases,  in  which
the urethra was entirely severed from the bladder, and the patients,
after  suffering  excruciating  torture  upon  the operating table, died
from  the injury done, with  the stone  unextracted,  the  bladder not
 having even been opened.   1 have known the gorget slip between
 the bladder and rectum, and patients lose  their lives with  the stone
 unremoved.   I have seen patients  opened after  this operation, in
 whom the gorget had injured the opposite side of the bladder.   I
 recollect other cases, in which the gorget  slipped between the blad-
 der and pubes, and, of course, the calculus never  bad an opening
 made for its extraction.   In one or  two cases, I  have known the
 rectum to be cut more than  the  bladder  itself.    Now, when it  is
 further considered,  that besides such mischief, arising from the slip-
 ping  or unskilful use of a well-made gorget, a  broad, badly con-
 structed, or an ill-directed one, may cut the pudic artery*, it must
 be confessed,  that there  is  great cause for  wishing that  lithotomy
 could alwavs be performed with an  instrument attended with fewer
 dangers.
   According to Klein, than whom  few  have written more sensibly
 on lithotomy,  that  method  of operating must  be  accounted the
 most advantageous, in which the surgeon  is best  enabled to make
 with  certainty the right kind  of  incision; that  is to say, in which
 the opening in the  bladder  may be  made larger, or smaller, as may
 be judged requisite; in which also the fewest instruments  are need-
 ed"  the least irritation produced; the operation most expeditiously
 finished; and in which the instruments will serve for every age and
 sex,  and for all cases, whether the stone  be  large or small.  A
 scalpel of proper size is the only instrument possessing  such rec-
 ommendations, and with it the operation can be perfectly executed.
   Question,— Whether the opening should  always be made  large
  * In using Cline'i gorget, Klein cut the pudic artery.  See Chir. Bemerkungen, p.
15. 
464                       OPERATIONS.
enough to let the stone pass out, without contusion and  laceration oj
the prostate gland and adjoining part of the bladder.
   Le Cat and Scarpa*  are  in favor of a very limited  incision, and
they insist on the  danger of  carrying it  at  all beyond  the  base of
the prostate gland; which method,  they conceive, would  expose
the patient to the  perils of an effusion of urine  in consequence of
the vesical reflexion of the deep perineal fascia over  the prostate
gland being divided.   This doctrine influences the practice of many
distinguished modern operators, amongst  whom may be enumerated
Dupuytren, Sir Benjamin Brodie, Mr.  Anthony White,  Mr. Lis-
ton, and  Mr.  Syme.   After having partly divided  the prostate
gland,  Sir  Benjamin Brodie introduces  a  blunt gorget  to  dilate
the wound, and split  the undivided  portion of the prostate.f   His
observations convince him, that an incision of the prostate, extend-
ing into the loose cellular texture surrounding the neck of the blad-
der, is  replete with  danger.   Such  a  division of parts  he  thinks
never necessary where the calculus is of moderate dimensions, but
cannot be avoided where it is of large size; and hence, the vast in-
crease of danger in the latter examples.
   On the other hand, Klein, one  of the most  successful lithoto-
mists in Germany,  lays down, as the basis of his  method, the ne-
cessity  of always  dividing, not only the prostate gland carefully
through, but  also  a  portion of the bladder itself.  " Upon this
basis,"  says he, "rests the success of my operations; and hence I
invariably make it a rule to let the incision be rather too large than
too small, and  never to dilate it with any blunt  instrument, when it
happens to be too diminutive, but to enlarge it  with a knife,  intro-
duced,  if necessary, several times."J  My  own observations lead
me to believe, that though  patients sometimes  die of effusion of
urine in the cellular tissue  of  the pelvis,  such effusion only happens
where the wound is not direct and free, the outer part  of it  being
too high up in relation to the cut  in the  prostate gland.   The  in-
ference, drawn  by me from the many post mortem examinations
which I have attended, is, that  effusion of urine in  the cellular tis-
sue of the  pelvis is not the usual  cause of  the  fatal inflammation
which ensues  in  the pelvis and abdomen, but  the injuries of the
bladder—sometimes a diseased one—from the protracted and rough
manoeuvres frequently  exercised to get a calculus  out of an opening
of very insufficient size.   The more easily the  stone has passed
out, the greater has appeared to me to be the success of the ope-
ration.  I am therefore an advocate for letting the incision be pro-
portioned to the size of the  stone, and  avoiding all laceration and
  * Memoir on Hawkins's Cutting Gorget.
  t On Diseases of the Urinary Organs, p. 278.
  X Practische Ansichten der Bedeutendsten Chirurgische Operationen, p. 27.  Che-
seldon anJ Martineau, who had  greater success,  perhaps, than any other surgeons,
also made a free opening. 
DANGERS OF  GORGETS.
465
contusion of the parts.  The  wound, of whatever size, should  al-
ways be direct: tbis will materially obviate the risk of efiusion of
urine, and  all occasion for the  use of a  tube to conduct  the urine
from the bladder  through  the  wound,—a  practice now  and  then
adopted, and, I believe, chiefly recommended, in the Edinburgh
schools.
   As the  questions, Whether a free incision through the  prostate
gland should be made? or, Whether this should be avoided as dan-
gerous, and dilatation and even laceration be preferred as  safer? are of
the highest, practical importance, and by no means definitively settled,
each view of the matter being supported by good authorities, the pres-
ent state of surgery appears to demand, that very correct information
should  be collected  on these  contested points.   In  particular, it
seems desirable  to ascertain  more  fully,  whether,  in fatal cases,
where a free and  direct incision has been made,  a common cause
of death  be really  effusion of urine in the cellular tissue of  the
pelvis?
   No  dressings  are  necessary directly  after the operation; but a
folded napkin, or sheet, is  to be placed under the nates^ and chang-
ed whenever it  becomes wet.*  Sir Astley Cooper does not con-
sider it necessary  to keep  the patient always  on  his back;  but says,
the patient will derive great  relief from lying  sometimes on his side.
The scrotum, he observes, should always be supported with a ban-
dage, so as to hinder it from  being  irritated  by the urine.f   The  pa-
tient may drink freely  of barley-water,  and afterwards of lemonade.
Sir  Astley Cooper gives his patients at first large quantities of linseed
tea,  or barley-water with gum acacia in it; and when the danger of in-
flammation is over, beef-tea, broth, or gruel.  Klein gives  an opiate,
as soon as the patient is put to bed; and on the second day, the bow-
els are opened with  a  clyster, or gentle purgative.   Sir Astley
Cooper sanctions  the exhibition of opium, if the patient be  very
irritable;  but, unless  absolutely necessary, dispenses  with it, as it
checks the action of the  bowels.   When  the wound  suppurates,
Klein dresses it with dry lint,  and  never finds any other application
requisite, except sometimes  a little caustic towards the end of  the
case.J   In proof  of the success of his method, he tells us, that in
1816, he bad cut into the bladder seventy-nine times, and  not one
patient bad died, unless where the prostate gland,  bladder, kidneys,
or ureters, were diseased.   Notwithstanding  the free division of the
bladder, most of the patients got well in from eight to fourteen days;
a few in a month; and one alone  was  three  months  in recovering.
Though the sphincter of the bladder was divided, no paralysis of it
* Sir A. Cooper's Lectures, vol. ii. p. 269.
t Vol. cit. p. 26S—270.
X Chirurgische Bemerkungen, pp. 37—48. 
466
OPERATIONS.
was the result.  Except when the calculi were large, or something
unusual happened, the operation was  completed in thirty  seconds,
or a minute.*   When  the wound  begins to granulate, Sir Astley
Cooper ties the legs together: if this be done  too  soon after the
operation, he  says, it hinders the free escape of blood  and urine
from the wound.f

                 OF WOUNDS OF THE  RECTUM.

   Unless the  operator  cut very carelessly, and turn the edge of
the knife directly downwards, instead  of  obliquely  sideways, the
rectum cannot be  injured.   With a  gorget, however, there is really
more danger of  such an accident, when  the instrument slips out of
thegroove of  the  staff.  Also, when  the rectum is distended with
feces,  it  is more exposed  to  injury;  but, why should  the surgeon
ever operate,  without having  previously emptied  that intestine?  I
once saw a case, in which  the rectum  was wounded  with  a lithoto-
my knife; but the cut  in  the bowel  healed, and never gave  any
trouble.

             OF WOUNDS  OF THE PUDIC  ARTERY.

   No  doubt,  some of the profuse  bleedings,  which have taken
place in lithotomy, have not proceeded from the pudic artery itself,
but either from  the artery  of  the  bulb,  when the  incision  was
made too high up, or, in other cases,  from  the trunk of the perineal
artery.  I am surprised, however,  that  M.  RouxJ should  assert,
that, in directing the incision too far laterally, there  is no risk at all
of wounding the pudic artery.  This  is  an  observation which is en-
tirely erroneous, and migh  encourage  the admirers of broad, long-
edged  gorgets  to  persevere  with their  instruments, until they had
learned from  experience,  that lithotomy can never  be done with
safety, unless  the  incision be made,  not only of sufficient size, but
in a proper direction.   Klein twice  had  the  ill  luck  to wound the
trunk of  the pudic  artery; the first  instance was  in a child  four
years of  age;  the  hemorrhage was suppressed  by introducing  into
the wound a piece of sponge,  which was removed on the fifth day;
the part was healed  in  a fortnight, but,  for nine weeks, an inconti-
nence of urine contined, which was ascribed to the  pressure  of the
sponge.§   The second case happened in a  patient, twenty-six years
of age, from cutting too much sideways  with Cline's gorget.  After
  * Pactische Ansichten der Bedeutendsten Operationen, pp. 28, 29.
  t Lectures, vol. ii. p. 269.
  X Relation d'un Voyage fait a Londres en 1814; ou Parall&le de la Chirurgie An*
gloise avec la Chirurgie Francoise, p. 322. 8vo. Lond. 1815.
  § Chirurgische Bemerkungen, p. 11. 
INFLAMMATION WITHIN THE  ABDOMEN.
467
the extraction of the calculus, the wound was distended with a linen
tent and  a, piece of  sponge; and the patient  kept quiet on the ope-
rating-table twenty-four hours, during all  which time the assistants
relieved  each other  alternately in  making pressure on the wound.
The patient lost four pounds of  blood in the operation; his pulse
was exceedingly feeble, and rapid; his  countenance  cadaverously
pale;  and his strength so much reduced, that  the greatest fears were
entertained for his life.
   When the trunk of the  pudic artery  is wounded, the  calculus
should be taken out, and the wound distended with sponge.*   If it
were  practicable to  tie this artery, it would  not be advisable, pre-
viously to the extraction of the  stone,  the  passage  of which out-
wards would inevitably force the ligature oft the vessel.f  In  one
case, operated upon by  Sir Everard Home,  Sir  Benjamin  Brodie
passed a ligature round the  pudic  artery  with  a small, flexible,  sil-
ver needle.   The  patient  was a very thin subject.:}:   Pressure on
the artery, where it crosses over  the spine of the ischium, was found
useful in stopping an alarming hemorrhage from a phagedenic ulcer
of the penis, in a case under Mr.  Travers§: the  same  plan might
also be worth trying for the stoppage of the bleeding after  lithot-
omy.

OF INFLAMMATION WITHIN THE  ABDOMEN  AFTER  THE  OPE-
                             RATION.

   The majority of patients, free from visceral  disease previously to
the operation, who die in consequence of lithotomy, perish of  pe-
ritoneal  inflammation.   Hence,  on  the  occurrence of  any tender-
ness, pain, and tension over the abdomen, with  great  restlessness,
thirst, heat of the skin,  and a small quick pulse, copious venesec-
tion should be  put in practice.   At the same time, twenty or thirty
leeches should be applied to the hypogastric region.   Much  bene-
fit will also be  derived from the  warm bath,  fomentations,  blisters,
the exhibition of oleum ricini,  andemollient clysters.
   I have seen several old  subjects die of the irritation of a diseas-
ed, thickened state  of the  bladder, continuing after  the stone had
been extracted.   They had not the acute symptoms, the inflamma-
tory fever, the general  tenderness  and tension of the abdomen, as
in peritonitis; but they referred  their uneasiness to the lower part of
the pelvis; and,  instead of dying in the course of two or three days,
  * A cannula should be passed through the  sponge, for the easy evacuation of the
urine.  See C. J. M.  Langenbeck iiber eine einefache und bichere  Methode  dea
Steinschnittes, p. 58. 4to. Wurzburg, 1802.
  t Klein, Op cit.  pp. 12—21.
  i Sir B  Brodie on Diseases of the Urinary Organs, p. 299. ed. 2.
  § See Harrison's Surgical Anatomy of the Arteries, vol. u. p. 101., and Morton 8
Surgical Anatomy of the Peiineum, p. 52. 
468
OPERATIONS.
as those usually do who perish of peritoneal inflammation, they, for
the most part,  lingered for two  or three weeks.   In such cases,
opiate clysters, and blistering the hypogastric region, are proper.
   In  some instances, collections of matter form in the vicinity of
the neck of the bladder.   Gangrene of the scrotum from  the vio-
lence used in the extraction of the stone, and  an  extravasation of
urine  in the cellular tissue, are  most likely to be avoided  by making
a direct opening into the bladder, and not beginning the incision too
high up towards the scrotum.  With  the same view, many opera-
tors avoid carrying  the incision in  the prostate gland  beyond its
base.
                       AMPUTATION.

Amputation  of limbs is  performed either  in  the continuity of
them, or in one of the articulations; each of which modes, howev-
er, cannot always be practised indifferently—the choice  depending
upon the situation, extent, and nature of the disease, or  injury, for
which the removal of the part becomes indispensable.   In all am-
putations at joints, it is the  general practice to make a flap of flesh
for covering the end of the  bone;  but when the operation is per-
formed at another part of the limb, it is frequently at the option of
the surgeon, whether the method adopted be amputation with one
or sometimes two flaps, or amputation by a circular, or an oval, in-
cision.  In this metropolis,  the circular  incision  is more common
than flap-amputation,  which,  however,  has now  many  advocates,
because, it is more quickly performed, and  consequently less pain-
ful, than the circular incision;  the  parts are cut smoothly, and left
in a state favorable to union; and  a  better  covering is afforded  to
the bones, than can be obtained from any modification of the other
operation.*
   That it is tbe quickest method of amputation, and that it  forms
an excellent covering for the ends  of the bones, I  believe is  gener-
ally admitted;  but some of the most experienced surgeons in Lon-
don, amongst whom is  Sir  Astley Cooper, are of opinion  that  a
stump,  after a flap amputation is generally followed by more co-
pious suppuration, and less frequently unites by adhesion, than ano-
ther formed by  the circular incision.   This is a point of importance
open to the observation of the profession  at  large, who have now
abundant opportunities, of coming to  a sound decision.  It seems to
me, that the quickness and facility of flap amputation,  the certain-
* See Syme's Principles, p. 198. 
AMPUTATION  OF  THE  THIGH.
469
ty with which the soft parts are smoothly cut, and the greater fre-
quency with which the protrusion  of the end of the bone  is avoid-
ed, are its principal advantages.   In particular cases, it is decidedly
the only method  applicable to circumstances; in others, the surgeon
may make his choice.
   Before proceeding  to  this description  of the methods of taking
off limbs,  let me just remind the  reader of one of tin best funda-
mental rules for our guidance in the  performance of amputation: "as
little of the flesh should  be cut away as possible; but the more bone
is removed, the better."*

            CIRCULAR AMPUTATION OF  THE  THIGH.

   The thigh should be amputated as low as the disease will allow.
The patient is to be placed on a firm table, with his  back properly
supported by pillows  and assistants, who are also to hold his hands,
and keep him from moving too much during the operation.  The an-
kle of  the sound  limb  is to  be fastened,  by means of a garter  or
handkerchief, to the nearest leg of the table.

                         TOURNIQUET.

   If this instrument be used, its pad should be  placed exactly over
the femoral artery in as high a situation as can conveniently be done.
When the  thigh is to  be  amputated far up, a tourniquet is inconven-
ient, arid, in tbis  case, an assistant is to compress the femoral artery,
as it passes over the os  pubis,  with his  fingers or thumb, or any
commodious instrument,  having a round blunt end, adapted  for mak-
ing direct pressure on  the  vessel,  without  injuring the  integuments.
   In amputation, the  greater number of  surgeons in this metropolis
still employ the tourniquet; but others prefer compression of  the
artery  by a trusty  assistant, when such  is at hand.  In  University
College  Hospital,  I   have never seen the tourniquet employed in
amputations.   If the   patient, however,  were exceedingly reduced,
I believe, that the tourniquet ought  to be employed.   Putting  out
of present  consideration  the assistant's liability  to  fail  in regularly
commanding the  flow of  blood  through  the artery, on account of
the violent struggling of the  patient, we  are to  remember that, be-
sides this vessel,  there are others roncerned  in  supplying the thigh
with blood, which are branches of the internal iliac, and come out
of the  openings of the pelvis; as,  for instance,  the arteria  obtura-
toria, the glutea,  and the ischiadica.   Hence, pressure upon the fe-
moral artery, below Poupart's ligament,  can never  stop  the bleed-
ing, but incompletely.   My colleague, Mr. Liston, objects to the
  * •« On doit couper des chairs le moins qu'il est possible, et des os, le plus qu'on
peut."  J. L. Petit, Traite des Maladies Chirurgicales, torn. iii. p. 150.
  VOL. II.                      40 
470
OPERATIONS.
use of a tourniquet, because compression on all the circumference
of a limb causes venous congestion in the whole of the member be-
low such compression, and a rapid oozing from the veins on the face
of the stump.  " I would rather trust  (says he) to no very efficient
assistant, than 'put  on a tourniquet."  I fully coincide with him on
one point, which is, that when a tourniquet is used, it should not be
put  on, till  the moment when  the surgeon is ready to  begin the
incisions.*

                       FIRST  INCISION.

   The operator is to stand  on the right side of the patient, whether
the right or left limb is to be removed.   By this means, he acquires
the advantage of always  having his left hand next  the wound,  so as
to be of very essential assistance.   This advantage more than coun-
terbalances the inconvenience of having the right limb in the way of
the operator, when the left thigh is to  be amputated.
   An  assistant, firmly grasping the thigh  with both hands,  is to draw
the skin and  muscles upwards, while the surgeon makes  a  circular
incision, as  quickly as possible,  through the integuments down to
the muscles.   When the integuments are sound in the place of the
incision and  above  it, their retraction  by the assistant before they
are cut through, and a very slight division of the  bands of cellular
substance with the edge of the amputating knife towards to point,
will generally preserve a sufficient quantity of skin for  covering, in
conjunction with the  muscles  cut in  a  mode about to be described,
the extremity of the bone;  and the painful method of dissecting up
the skin from the fascia,  and turning it back,  previously to  dividing
the muscles,  may be considered useless and improper in all  amputa-
tions of the  thigh, where the skin retains its natural moveableness
and elasticity.
   It appears to Mr. Guthrie,  that, in primary amputations,  or those
done at an early period after the receipt of a gunshot injury, while
the part of the limb, where the incisions are to be  made,  is  in the
natural state, and the skin loose and moveable, " it will be sufficient
to touch the  thread of membrane, or  fascia adhering  below,  with
the point of  the same (the amputating) knife, to give ample cover-
ing for an excellent stump, without putting the patient to the torture
of having his skin pinched and  dissected back, for the space of  a
couple of inches,  for four or five minutes."   At the same time, he
particularly insists on the utility of dividing  the  fascia and integu-
ments together, by which means, the latter can be retracted much
further than  would otherwise happen.
   In operations, however,  performed from the third to the twelfth
day after the receipt  of the wound,  and  near the injured parts, Mr.
* See Elements of Surgery, Part iii. pp. 361, 362. 
AMPUTATION  OF THE THIGH.
471
Guthrie admits of the propriety of dissecting the integuments a little
way up from the fascia, as in these cases the retraction, effected by
the assistant, and the natural elasticity of the skin, will not avail in
saving enough of it  to  cover the  surface of the stump well;  yet
even here he rightly disapproves  of  turning back the  separated  in-
teguments, as is often done, like  the top of a glove.
   " In secondary amputations," says he,  " with  the exception of
those, in which the operation is required in  parts actually unsound,
the  integuments  may be sufficiently  retracted, without any formal
dissection of them from  the subjacent fascia."*
   I have said, that the surgeon is to begin the  operation by making
an incision through the skin all round the limb.   The generality of
surgeons, rightly considering this as  one of the most painful parts of
the operation, do it with as much quickness  as possible, and there-
fore carry the knife all round the member with one sweep, the hand,
which holds the knife, being carried round under the  limb  until the
edge can be placed perpendicularly  on the skin covering the exten-
sor muscles.  Excepting the appearance of greater skill, and a little
greater quickness, however, the foregoing mode of dividing  the skin
all  round the  limb  with one stroke of the knife, has no particular
advantage over the method of completing the cut with  two sweeps
of the knife.

                  OF DIVIDING  THE  MUSCLES.

   The ancient surgeons  used to cut  directly down to the  bone at
once,  and the frequent  consequence  was  a conical  or sugar-loaf
stump, extremely  unfit for bearing  any degree  of pressure, and,
therefore, kept healed with difficulty.  The end of the bone, in fact,
often protruded  beyond  the soft  parts.   At length,  however,  the
improvement was made of cutting the integuments through first,  and
then the  muscles:  a  method, well known amongst surgeons by  the
name of the double incision.
   But, although  the  double incision enabled  the  surgeon  to save
skin, and saw the bone higher up, a conical  stump, and projection
of the bone, sometimes  followed.  The  great innovations, which
ultimately proved nearly effectual in the prevention of such tedious
miserable cases, were, besides the saving of skin, the oblique divi-
sion of the muscles, suggested by Alanson; the cutting of the loose
muscles first, and the fixed ones  afterwards, proposed  by Louis;
and the  immediate closure of the wound,  after  the bleeding  had
been stopped, the great utility of which was first brought to light in
the early trials of what are called flap-amputations.
  * G. J. Guthrie on Gunshot Wounds of the Extremities, requiring the different
Operations of Amputation, with their alter Treatment, &c. pp. 84, 85.  8vo. Lond.
1815. 
472
OPERATIONS.
   M. Louis, for whose memory every admirer of surgical science
ought to entertain sincere respect, first discerned the principal cause
of the projection of  the bone.   He  observed, that  the muscles of
the thigh became  retracted  in  an unequal manner  when divided;
those which are superficial, and extend along the limb more or less ob-
liquely, without being attached to the bone, becoming retracted with
greater force than  others which are deep, and, in some  measure,
parallel to the axis of the femur, and fixed to this bone throughout
their whole  length.   Their  retraction begins at the moment of  the
operation, and,  for  some time afterwards,  continues unfinished.
Hence, the  effect should be promoted, and be as complete as possi-
ble, before the bone is sawn.   With this view, M. Louis practised
another kind  of double incision: by  the  first, he  cut,  at  the  same
time, both the integuments, and the loose superficial  muscles;  by
the second, he divided those muscles, which are  deep, and  closely
connected with the femur.  On  the  first  deep, circular  cut being
completed,  M. Louis used to remove the band encircling the limb
above the track of the knife, in order to allow the divided muscles
to become  retracted without any impediment, and he  then  cut  the
deep  muscles, on a level with the surface of those which had been
first divided, and which were now in a retracted state.   In this way,
he could  evidently saw the bone very high up, and the painful  dis-
section of the skin from  the muscles was avoided.*
   Alanson's mode of amputating was as follows:—The integuments
having  been  divided by a circular  wound,  the  knife  was  applied
close to the  margin  of the retracted  skin, upon the inner  edge of
the vastus internus,  and, at one stroke, an  incision was made  ob-
liquely  through  the muscles, upward  in respect  to the limb,  and
down to the bone: in other words, the cut was made in a direction
which laid the bone bare, about twTo or three fingers' breadths higher
than a perpendicular incision would have done.   The operator now
drew tbe knife towards  himself, so that  its  point rested upon  the
bone, still observing to keep the instrument in the same oblique  po-
sition, in order that the muscles might be divided all round the limb
  * See Memoire sur la Saillie de l'Os apr^s 1'Amputation des Membres; ou I'on ex-
amine les causes de cet inconvenient, les rnoyensd'y rt'me'dier, et ceux de la pr»'venir.
Also, Second Memoire sur I'Amputation des irlembres, ,M'm <ie V Acad, de Chirurgie,
torn. v. p. 244. and 401. edit, in 12mo.   And IVouvelles Observations sur la Ri'tract ion
des Muscles apres  ('Amputation de la Cuisse, et sur les Moyens de la prevenir.  Op.
Cit. torn. xi. p.  63 edit,  in 12mo.  Baron Dupuytren's  mode of amputating was as
follows:—With one sweep of the knife he divided the integuments and muscles down
to the bone, most frequently perpendicularly, but sometimes obliquely.  The retrac-
tion of the soft parts by the assistant who grasped the limb, and the contraction of the
muscles, instantly  gave to the wound the shape  of a cone.  At ihe base of this cone,
and on a level with the retracted skin and muscles, he applied the knife  again, and
cut through whatever soft parts presented themselves there. 1 hus he was enabled
to saw the bone more than six inches above the first incision, and to complete the
operation with surprising quickness.  (See  Lecons  Orales de Clinique Chir. t. 4. p.
298.)  By this method, the patient is saved from all the pain of dissecting the skin
from the fascia, or the fascia from the muscles.  It is as quick as a flap-amputation. 
AMPUTATION  OF THE THIGH.
473
in that direction, by a  proper turn of the knife.   During  the per-
formance of this movement, the point of the knife was kept in con-
tact with the bone round which it revolved.*
  Many writers have  objected  to the difficulty of making  the ob-
lique incision exactly as Alanson has directed, and Mr. Hey even
questions the possibility of the  practice, without  a different result
from what was intended.   It is evident (says Mr.  Hey) that a coni-
cal incision  through the muscles of the thigh cannot be made with a
continued stroke, in the usual mode of amputating.   For, supposing
the edge of the knife to have once penetrated obliquely through the
muscles, so as to be an inch higher, when arrived at the bone, than
when it  penetrated the surface; if the incision be continued with a
flowing stroke, the knife must then cut the surface of the undivided
muscles an  inch higher than at the commencement of the incision.f
 How far it  is actually  practicable to keep the point of  the  knife in
contact with an exact  circle on the bone, during the oblique passage
 of the instrument all round the member, it is not for me to  say, be-
 cause, seeing its difficulty, I have  never attempted it; nor can I
 suppose, that  Alanson himself ever really did what he literally rec-
 ommends.   Of one thing also I am sure, that  I  have  seen many
 surgeons, in their attempt to do this business after Alanson's direc-
 tions, get so high up as to cut the reflected skin.
   The late Mr.  Hey  is not  the only, nor the earliest  writer, who
 has  pointed  out  the inaccuracy of Alanson's  directions.   Richter
 has offered several judicious criticisms  upon them, which perfectly
 coincide with  Mr. Hey's  views.   It  is remarked, that  when  the
 knife, with  its edge turned obliquely upwards, has  reached the bone,
 a flap is actually formed on the side where  the incision  is practised:
 and  the edge  of the knife  is now three inches higher  than the cut
 in the skin.   In this state the surgeon cannot possibly  continue tbe
 incision.  The only thing  which he can  now  do, is to place the
 knife on the opposite  side of the thigh in the same manner, and make
 a flap there.   The  operation, says Richter, is  then rather a flap-
 amputation*, not done  in the best wa\, than  an operation really prac-
 tised as Alanson thought possible.   By following precisely his in-
 structions,  Richter thinks it  would be quite impracticable to  form
 a hollow stump, though perhaps it  might be done by reiterated ob-
 lique strokes of the knife all round  the limb.   But, he  exclaims,
 what a stump  there would then be, and what a method  of operating!
  He comments also on the  difficulty of making a knife cut  properly
 by  mere pressure, as  would  be the case, were its point kept unre-
 mittingly against the bone, in carrying the incision round the member;
 on  the preferable  nature of amputation with a flap to this method,
* See Alanson's Practical Obs. on Amputation, 2d ed.
t Hey's Practical Observations in Surgery, p 529. cd. 2.
             40* 
474
OPERATIONS.
the wound left by which  is longer in healing;  and on the pain and
delay of separating the skin to  be saved,—a proceeding altogether
unnecessary in amputating with a flap.*
   Many excellent surgeons, whom I have seen operate, do not cut
at once obliquely down to the bone, after the integuments have been
divided and retracted; but so far adopt the principles of M. Louis,
as to  divide the loose muscles first, and lastly, those  which are in-
timately attached to the bone, taking care, with a scalpel, to cut com-
pletely through the deep  muscular attachments, about an inch  higher
up,  than could  be  executed  with  the amputating  knife  itself.
This  last measure causes very little pain, and has immense effect
in averting all possibility of a  subsequent  protrusion of the bone,
or of a bad sugar-loaf stump.   Such  used to be  the practice of
Mr. Hey, who  calls it  the triple incision]: and Mr. Guthrie,|
in his account of amputation of the  thigh, is a  decided  advocate
for a  similar mode.  In this method, however, the  advantage of
the oblique incision through the different layers of muscles, was in-
variably retained.   I believe that, in the circular amputation  of the
thi^h, a combination of the principles of Alanson with those of M.
Louis,  is the best.   However,  I am obliged to confess, that the
attempt to divide the loose muscles first, and  then the more fixed
ones, is apt to make a hasty surgeon cut  the whole, or a great part,
of the  same muscle  through  more than once;  a fault, which de-
serves to be reprobated in  the strongest terms.

                   USE  OF  THE RETRACTOR.

   Having cut completely down to the  bone, a piece of linen, some-
what  broader than the stump, should be  torn  at one end,  along its
middle  part, to the extent  of about eight or  ten inches.  This is
called  a retractor, and  is applied by  placing the exposed  part of
the bone in the slit,  and  drawing the  ends of the linen  upward on
each side of the  stump.   Thus the  retractor will  evidently keep
every part of the surface of the wound out of the way 'of the saw.
In circular amputations,  I have seen the  saw do so much  mischief,
in consequence of neglecting  to use  the retractor, that when  the
amputation  is performed with  a circular incision, my conscience
obliges me to censure the employment of the saw without a defence
of the soft parts  by this  simple contrivance.  I  think no one will
say, that the retractor can  do harm; and  I know, that  many who
have  been with  myself  eye-witnesses of the mischief, frequently
done  by the saw in amputations, are deeply impressed  with an
aversion to the neglect of this bandage.   I have often seen  the soft
* Anfangsgr. der Wundarzn. b. vii. p. 187.
t Hey's Practical Observations on Surgery, p. 526. edit. 2.
X On Gunshot Wounds of the Extremities, &c. p. 86. 
AMPUTATION OF THE  THIGH.
475
parts skilfully divided; and the operators,  directly afterwards,  lose
all tbe praise, which every one  was ready to bestow, by their liter-
ally  sawing through  one half of the ends of the muscles,  together
with the bone.   But,  besides  defending the surface of the stump
from the teeth  of the saw,  the retractor will  undoubtedly enable
the  operator to saw the  bone  higher up,  than he otherwise could
do.*

                    OF SCRAPING  THE BONE.

   Another proceeding, not to be imitated,  is the practice of scraping
up the periosteum with the knife, as  far as the muscles will allow.
This is a sentiment, in which I  must still  continue to join  the ex-
perienced  and  judicious  Petit, notwithstanding a  modern  authorf
has actually devoted a section of his book to the praise of  what is
here particularly condemned.   The chief argument for the practice,
urged by Bri'mninghausen, is, that, by scraping the  periosteum up-
wards  from  the  bone,  a  portion  of the detached  membrane
will  yet remain  connected to the muscular  fibres, thus pushed back,
and  afterwards  admit of being  brought down with  them over  the
sawn bone.   As, however, I have seen the  bone extensively scraped,
without an exfoliation being  a regular effect of the method, I do not
consider, as Petit did, that a part of the bone must inevitably die,
after the periosteum,  is thus freely  scraped away; but I look upon
the improper and useless  separation  of this membrane as one of the
circumstances,  which  tend to produce  the exfoliations that  some-
times happen after amputations.   At all events,  it is a superfluous
measure, as a sharp saw, such  as ought  to be employed, will never
he impeded by  so slender  a membrane as  the  periosteum.^   All
that  the  operator  ought to do is, to lake  care  lo cut completely
down to the bone, round the whole of its circumference.   Thus  a
circular division of the periosteum  will  be made, and here  the saw
should  be placed.
  * J. L. Petit earnestly recommends the employment of a linen retractor; when a
surgeon once told him, that he did not use it, because the teeth of the saw were apt
to get entangled in it, he answered:  «' II est vrai que cela peut arriver lorsqu'on tie
sail pas le placer; les meilleures manhres d'opt'rer ont leur inconvenient, si on w'g-
lige les circonstances qui les font reussir."  Traite des Maladies Chir. t. iii. p.  152.
Dupuytren is another distinguished advocate for the use of the retractor.  See Lecons
Orales,  &c, t 4.  p. 299.
  t It. J. Briinninghausen, Erfihrungen und Bemerkungen iiber die Amputation, p
67.  Bamberg, 1818.
  t Petit's opinion is thus expressed: Si par trop  d'exactitude, on dt'pouillc trop en
avant b-s os de leur p'rioste,  ('exfoliation, qui devient inevitable dans ce chs, se fait
long temps attendre, et retarde be.iucoup la prison; je pnf re done de scier le pe-
rioste, avec les os; j'ai toujours t'prouvc que cette rmthodo etoit moins douloureuse et
qu'elle eviait souvent I'eiLfoiiation."  Vol. cit. p. 158. 
476
OPERATIONS.
           OF  THE  MANNER OF  SAWING  THE  BONE.

   As Petit justly remarks, that this part of the operation is by no
means easy to a person unaccustomed to handle a saw.   The prin-
cipal difficulty  arises from the bone being sawn up in the air  (as it
were); at least the part is in general but very imperfectly fixed by two
persons, who,  however strong they may be, cannot resist  the saw,
and hinder the  limb  from  being shaken, whereby the  direction of
the instrument becomes altered.   Besides the  two assistants rarely
act so  well in concert together as  always to hold the limb in  the
same direction, and with an equal  degree of strength.   It is true, such
irregularity is not of  much consequence at  first, while the bone is
not half sawn through:  but, as  soon as the  instrument has cut  to
this depth, the  irregular movements of the assistants,  who hold  the
limb, make the sawn surfaces  come nearer together, and the saw is
so pinched, or  locked betwixt them, that it  cannot stir,  in one  di-
rection or the other.
   A skilful surgeon  (observes Petit)  may obviate the difficulty by
supporting the  part with his left hand, as Mr.  Liston actually pre-
fers, and resisting or yielding  at seasonable opportunities to such
circumstances as impede the motion  of the instrument.   But  the
difficulty may depend upon the saw itself, when its blade is not duly
stretched, the  teeth  not well turned alternately to the  right and left,
their points not in good order, their edges not sharp enough, or they
are not filed obliquely, so that the bone-dust may be readily thrown
off to each side.   The latter object requires also, that the blade of
the saw at the teeth part should  be rather thicker than the rest of it,
or else the fissure in the bone  would be completely filled with  the
instrument, and the bony particles, not easily  escaping, would ob-
struct the movements of the saw.   In  order to saw the bone  as
close to the flesh as possible, Petit says the nail of the index finger
is  to be placed on the point where the  sawing is to begin.   Many
surgeons,  however, find it  more convenient to use the nail of  the
left thumb for this purpose.   The flesh being retracted, the saw is
now to be  applied exactly at  the angle formed by the nail and  the
bone;  and the instrument  is  to be worked  very gently  and with
scarcely any  more  pressure  than  that of  its own  weight, until a
groove is cut,  from which it will not start:  then  the  force is to be
gradually increased.*
   The saw should cut with both edges,  whether the instrument be
moved  backwards or forwards,  by  which means, as  a modern wri-
terf has remarked, the operation will be  expedited,  and the splint-
ering of the bone, when it is nearly divided, prevented,  inasmuch
* Petit, Traite des Maladies Chir. t. iii. p. 159, 160.
t G. J. Guthrie on Gunshot Wounds of the Extremities, &e. p. 89. 
AMPUTATION  OF  THE  THIGH.
477
as the surgeon,  when he uses a saw which cuts in both directions,
has it in  his  power to finish  the latter part of the  division of the
bone entirely  with backward  sweeps  of the instrument,  which are
always the most regular and gentle.
   In  order to  form the  groove for the saw, it is best to begin  by
drawing the instrument across the bone with a backward sweep, the
teeth  near the handle being first applied to  the  part  close to the
operator's left thumb or fingernail, and the  whole extent of the edge
is then to  be  steadily and briskly drawn back to the  point.   The
movements of  the saw should never  be short and rapid,  but every
stroke of  the instrument should at first  be long, bold, and regular,
without too much  pressure.   When  about two thirds of the bone
are cut through, the  pressure and force must be lessened, and, to-
wards the  end of the business, two or three gentle movements  of
the saw  backward  will complete it,  without  risk  of an  extensive
splintering.  In the latter part of the sawing, the assistant who holds
the leg, must be careful  to avoid depressing the condyles  of the fe-
mur, as it  would inevitably break the  bone, previously to  its com-
plete  division.   Indeed, it is difficult  to say, w-hether  this misman-
agement, or the rough, unskilful mode of using the saw itself, is the
most frequent cause of the latter accident.   The assistant certainly
has rather  a  delicate task to perform, because if he raises the limb
too much, he  pinches  the saw;  if he  depresses it, he breaks and
splinters the  bone.*
   if the bone should break,  before the sawing is finished, the sharp
projecting spiculae, thus  occasioned,  must  be removed by means of
the bone nippers.

                OF  STOPPING  THE  HEMORRHAGE.

   After  the  removal of the  limb, the femoral artery is to be taken
bold of with a pair of forceps, and  tied, without including the ac-
companying  branches of the anterior crural  nerve in the ligature.
None of the  surrounding flesh ought  to be  tied;  but the ligature
should be placed round the artery, just where it emerges from its lat-
eral connections.   D&sault recommends tying the  femoral vein,  as
well as the artery;  because when the  former remains  open, and the
bandage  compresses the upper part of the limb too  forcibly, the ve-
nous blood returns downward, and hemorrhage takes place.f  Mr.
  * It is on this account that Mr.  Lfaton insists upon the rule, that the management
of the lower part of the limb should'always be by the person using the saw.  See
Elein. of Surgery, Part iii. p. 364.
  t OZuvres Chir. de Desault par Bichat, torn. ii. p. 550.  Venous hemorrhage al-
most always ceases on the removal of the tourniquet, or any other tight bandage.  At
the present day, indeed, the practice of tightly bandaging stumps is completely aban-
doned in London. 
478
OPERATIONS.
Hey also met with a few instances of bleeding from tbe femoral vein,
and therefore he  generally inclosed it in the ligature along with the
artery.*   The risk of bringing on phlebitis, however, should teach
us to abstain from this practice, which is not necessary, because com-
pressing the mouth of the vein a minute or two with the finger, will
put an end to the bleeding  from it, provided the tourniquet is re-
moved, and no bandage applied.   The smaller  arteries are usually
taken up with a single or double tenaculum.   After tying as many
vessels as require it, one half of each ligature is to be cut off near
the surface of the stump.   The  right  qualities  of ligatures, used
for securing blood vessels, having  been considered in the chapters
on hemorrhage and aneurism, it  is unnecessary now to  return to
that interesting topic; nor shall I speak  here  again of the proposal
of moving both ends of the ligature, close to  the knot.
   When the large bleeding  vessels have been tied, the  tourniquet
should be slackened, and the wound well cleaned,  in  order  to de-
tect any vessel,  which may lie concealed with  its orifice blocked
up by coagulated blood; and, before  the dressings are applied, the
whole surface of the wound should be examined with the greatest
accuracy.   By this means, a pulsation  may often  be discerned,
where,no hemorrhage has previously  appeared,  and a small  clot of
blood  may be removed from the mouth of a considerable artery.
As the lodgment of much coagulated blood would be  unfavorable to
the speedy union of the wound, the surgeon  has an additional mo-
tive for being careful to make its whole surface clean with a sponge
and water, before it is finally closed.   The number of arteries, re-
quiring to be tied, will depend very much upon the incision  having
been  made in sound and uninflamed parts, or upon  parts  in  a state
of inflammation, swelling, and disease.   This accounts for the truth
of an observation, made by military surgeons, that, in amputations
performed immediately, or soon after the receipt of an injury, there
are fewer vessels to be  taken up, than in what are  termed seconda-
ry, or long delayed operations.!
   I have occasionally seen examples, in which it was not necessary
to take up a single artery.   A young child was run over by a hack-
ney coach, the wheel of which crushed  the  lower part of the  leg,
and rendered immediate amputation necessary.  The operation was
done  by the late Mr.  Ramsden, without delay;  no vessel was tied;
and the stump healed without any  subsequent  bleeding.   Some in-
stances have also fallen under my notice, where  arteries like  the ul-
nar and anterior tibial, even in adults, require  no ligature.  The ab-
sence  of  hemorrhage is sometimes explicable by the clot of blood,
formed in the large vessels in cases of gangrene.   Thus, a modern
surgeon tells us,  that he amputated the arms of  two Cossacks, four
* Hey's Practical Obs. on Surgery, p. 530. ed. 2.
t See Guthrie on Gunshot Wounds, &c p. 90. 
AMPUTATION  OF THE  THIGH.              479
months after the limbs had been shot through above the elbow, and
while they were aftected with hospital gangrene:  not a vessel was
tied; no secondary hemorrhage arose; and the stumps healed in the
most favorable manner.*

                   OF DRESSING THE  STUMP.

   The skin and muscles are now to be placed  over the bone, in
such a direction that the wound may appear only as a line, across the
face of the stump, with the angles at each side, where most of the
ligatures  are to be  brought out, as  their  vicinity  to their  angle
directs.   The skin is commonly  supported in this position by long
strips of  adhesive plaster, applied from  below upwards,  across the
face of the stump.   Over these, and the ends of the ligatures,  it
is best to place some pieces of lint, spread with the unguent, cetacei,
in order  to  keep them from  sticking,  which becomes  a  trouble-
some circumstance, when the dressings are to be removed.   I am
decidedly averse to the plan of loading  the  stump with  a  mass of
plasters,  pledgets, compresses,  flannels, &c.   I  see no  reason
why the strips of adhesive plaster, and a pledget of simple ointment,
should not suffice,  when supported  byjwo  cross  bandages, and a
common  linen roller, applied  not too tightly round  the limb,  from
above downward.  The first turn of the roller,  indeed, should go
round the patient's body;  and, being continued  down, will fix the
two cross bandages over the end of the  stump.  Here, as after all
other operations,  the dressings should generally be superficial, and
make no compression:  if the vessels have  been  properly secured,
there is no risk of hemorrhage; and if they  have not, it is not a lit-
tle degree of constriction that  will hinder bleeding.   Besides, much
pressure  has the  serious  inconvenience of causing a tendency to
bleeding depending on  obstruction  of the  venous  circulation ; ir-
ritating the  parts;  exciting inflammation and suppuration, causing
 absorption of the cellular tissue, and a  sugar-loaf stump.f
   When  the weather is not too cold, it  is an excellent rule to  dress
stumps lightly, and to cover them with linen, or  lint,  wet with cold
 water.   Mr. Liston commonly follows this  plan,  using two or three
sutures, and no adhesive  plaster, till the oozing of blood  has entire-
 ly ceased, at the end of about six or eight hours.   Then he has re-
 course to slips of oiled silk,  rendered  adhesive with a  solution of
 isinglass in brandy.  Interstices are  left for the sutures and liga-
 tures.  These isinglass plasters  do not  irritate, and are not loosen-
 ed by the discharge.   After  twelve  or twenty-four  hours, the su-
 tures are cut and removed.   If the case prove favorable, Mr. Lis-
  * Klein, Practische Ansichten der Bedeutendsten Chirurgischen Operationen, lte«
Heft. p. 62. 4to. Stuttgart, 1816.
  t CEuvres Chir. de Desault, t. ii. p. 552. 
480
OPERATIONS.
ton finds no change  of  dressing requisite, till the stump is healed.
It was the custom of Dupuytren  to Jet more  than an hour elapse
before the stump was dressed,  in order that he might not be obliged
to take off  the  dressings again by the quick return  of bleeding.*
The partis  kept cool, and the discharge, if it be sufficient to fall on
the oiled cloth covering the  pillow,  on which the stump is laid, is
wiped away from time to time.
   If the common mode  of closing stumps with adhesive plaster be
adopted, the dressings should  never be  removed  before  the third
day ; but, in general, it  is quite soon enough to change them on the
fourth or fifth :  when ,the weather is  hot,  and  there  is much dis-
charge, they should  be  taken off earlier than under other  circum-
stances.   The favorable healing of a  stump will depend very much
upon ihe skill  and tenderness with which the dressings are changed,
more especially  the first dressings.   In order to facilitate ihe re-
moval of the plasters, they should be first thoroughly wet with warm
water, which is not to be rubbed upon them with a sponge, but al-
lowed to drop, or flow over them.   Each strip of plaster should be
taken off, by raising its  ends,  and drawing them gently up together
towards  the extremity of the stump,  by which means the surgeon
will  avoid pulling the recently united  parts away from each other.
During the  change  of the dressings, an  assistant is always to sup-
port the flesh and keep  it from being retracted ; and  for the more
complete prevention of the same disadvantage,  it is a good  rule ne-
ver to let every strip of  plaster be off the limb atone  time  ; but, as
soon as some are removed,  to put  on others,  before  the  rest are
loosened  and  taken away.   It is  hardly  necessary  to add,  that,
when matter is collected within the stump,  it should be gently com-
pressed out  with a sponge, in doing which the pressure should be so
regulated, as not to force back the flesh.
   At the end of five or  six  days, the surgeon may begin to try, in
a gentle  manner, whether any of the ligatures are loose.  However,
he should not use the smallest force, nor persist, if the trial create
pain.  One would  hardly try, whether the  ligature on the femoral
artery were loose before the fourteenth or sixteenth day.

              FLAP-AMPUTATION  OF THE THIGH.

   Although this operation is not universally regarded as  the best
method  for  ordinary cases, its advantages, under particular circum-
stances, are generally acknowledged, and it is  unquestionably a ra-
pid and showy method.  In  Germany, flap-amputations  seem to
have numerous  advocates;  and, I  believe, that  whoever  will take
  * Leyons Orales, &c. t. iv p. 332.  I believe, that we are now falling into the se-
rious error of leaving stumps loo long unclosed, so that the exposure of the wound
leavesjittle or no chance of union of any part of it by the first intention. 
AMPUTATION OF  THE  THIGH.
481
the trouble of inquiring into the actual state of surgery in that coun-
try,  will find this method of operating quite as  frequently practised
as the circular incision.*   Desault employed  both modes on the
thigh, or  arm, indifferently; though  he did not adopt flap amputa-
tion in the leg, or fore-arm.f   In  England,  where the latter meth-
od first originated  with Lowdham, and  where,  at various periods,
it has been strongly commended and  improved by several men of
great eminence,  it has not retained so many advocates  as in Germa-
ny and Scotland, where the successful manner in which it was prac-
tised  by Mr. Liston, and the able  remarks of Mr. SymeJ in its fa-
vor,  made it the common method.
   All  British surgeons  agree, however, that  flap-amputations are
generally the best, when  a  limb is  to be taken off at a joint,  and,
also,  in every instance in which the skin and soft parts  are  quite
sound on one side of a member, while, on the other,  they are dis-
eased, or destroyed  for a considerable extent  upwards.  Here,
amputating with  a  flap  will be the  means of preserving more of the
limb  than could be saved by the circular  incision, and  becomes
praiseworthy on  the very same principle, which has sometimes been
thought to render  the  latter method most eligible under ordinary
circumstances.                          '
   As Mr. Hey  has remarked,  sometimes  the integuments of the
thigh are in a morbid state on one side  of the limb, while they are
 sound on the other.   In this case, a longer  portion of integuments
and muscular flesh must be left on the sound side; which will not
 prevent the formation of a good stump.   The morbid state of the
 anterior or posterior  side of  the  thigh  sometimes  extends  so  far
 above the knee, that it is advisable to amputate with a flap§.
   Were the thigh-bone  injured high up, and had gangrene extend-
 ed about the trochanter major and posterior upper part of the  thigh,
 if the head of the femur were sound, and the patient able to bear
 the operation, I would make  a flap at  the inner and  upper part of
 the member.||   Indeed,  a flap-amputation of the thigh must always
 be attended with some difference, according as the soft parts on all
 sides of the limb  happen to  be sound,  or not.   When, in  conse-
 quence of the  flesh being severely injured, or diseased on one side,
 the flap must be entirely formed on the other,  it  will  be necessary
 to save more skin and  muscle in the latter situation, than  if the sur-
 geon had it in his  power to form two flaps for  covering the end of
  * Consult C. C. Siebold, Diss, de Amputatione  femoris cum relictis duobus carnis
segmentis, VVirceb.  1782 ;  Grafe, Normen fur die Ablosung grosserer Gliedmassen.
Berlin, 1812;  Richter, Anfangsgr. der  Wundurzneykunst, b. vii. ; Kap. 7. Svo.
Guttingen, 1804; Klein, Practische Ansichten der bedeutendsten Chirurgischen Ope-
rationen,  ltes Heft.  4to.  Stuttgart, 1816; H. J.  Brunninghausen, Erfahrongen und
Bemerkungen uber die Amputation, 12mo. Bamberg, 1818.
  t CEuvres Chir. de Desault, t. ii. p. 547.
  X See Edinb. Med. &. Surg. Journ. 1823.
  § Hey's Practical Obs. in Surgery, p. 531. ed. 2.
  || See Klein's Ansichten bedeutendsten Operationen, pp. 39—42, &c. ltes Heft.
   VOL.   II.                    41 
482
OPERATIONS.
the bone.   If possible, however, there  should  be two flaps, and
placed laterally, or anteriorly and posteriorly, according to circum-
stances.   In an  operation high  up the limb, if the flaps be lateral,
Mr. Liston  finds that there will be risk of a protrusion of the bone,
because no muscles are left to  oppose the muscles inserted into the
trochanter minor,  which will then  raise the bone involuntarily to-
wards the abdomen.  Hence,  in  this part  of the thigh, he prefers
anterior and posterior flaps; for, then the more the stump is raised,
the better is the end of the bone  covered; the  anterior flap folds
over it."  He  recommends  the  posterior  flap to be  made  rather
longer than  the  anterior.   In   the lower part of the  thigh, lateral
flaps are the best.*  If the limb  is  to be taken  off at, or below its
middle, the  pad of the tourniquet, if this be used at all, should be
applied to the femoral artery, where it  lies  between  the  sartorius
and adductor longus; but, if the operation is to be performed higher
than this, the tourniquet would  interfere with the knife, and prevent
the due retraction  of the muscles, and, consequently,  it is  better to
compress the femoral artery as it is  passing over the os pubis.  In
making the first  flap, which I think  should  be an external one,  in
order not to cut the femoral artery  in the commencement  of the
operation, the  point  of the knife, the edge of which is  directed
down towards the knee,  should pass perpendicularly till it  touches
the bone, round the outer side  of which  it   is to be  closely guided,
and then pushed through the integuments in the central line of the
posterior part of the limb.  With  a gentle sawing motion, the ex-
ternal flap is then  to be formed, consisting of the integuments, fas-
cia, and part of the cruralis, and rectus, and of the vastus externus
and  biceps  muscles.  The length of the flap must  depend  on the
diameter of the  thigh; but, in general, from three to four inches will
be sufficient; for, if the flap be too long, it rarely unites favorably.
 The  point  of the  knife is then  to  be introduced perpendicularly
again at the anterior and superior angle, of  the  external flap, till  it
touches the bone, closely round which it is to be conveyed,  till it is
in a position to  pass  through the limb  precisely at  the upper and
posterior angle  of the external flap.  The transfixion having been
made, the internal flap is  then formed  by cutting downwards and
inwards to the point  chosen as the limit of its length.  The bone
having been sawn  through, and  the arteries secured, the  flaps are
brought together with two or three sutures, so as to meet  in a per-
pendicular line, and lint dipped in cold water laid over the  stump,
until  all oozing of blood  has  ceased, when common adhesive, or
isinglass plaster, may be applied, and the sutures removed.  The
inner flap will comprehend the integuments, the  fascia, part  of the
 cruralis, adductor, sartorius, gracilis, semimembranosus, and semi-
tendinosus,  with the femoral artery, vein,  &c.
* See Liston's Elements, Part iii. p. 394. 
AMPUTATION  AT THE HIP-JOINT.           483
               AMPUTATION AT  THE  HIP-JOINT.

  In  this operation, the following  circumstances  merit recollec-
tion:—
  1.  The acetabulum not  being deep enough to contain the whole
of the head of the femur,  and the latter being partly embraced by
the orbicular  ligament,  this  ligament, if not  divided  close  to the
brim of tbe acetabulum, will form some impediment  to the dHar-
ticulation.   2.  When the thigh is in  the position of abduction, the
ligamentum  teres is rendered  tense by the head of the femur, and
readily presents itself to the edge of the knife.   3.  If it be intended
to form two flaps of equal size, they should be separated by a line ex-
tending from the great trochanter to the opposite point of the diameter
of the  limb.  4. As the femoral artery corresponds above to the junc-
tion of the middle third of the head of the femur with its internal third,
and only gets  parallel to the  bone three  or four  inches lower down,
there must necessarily be between the artery and  the neck of the
femur, for  a considerable part of this  extent,  a distance  of fifteen
lines,  which, in several modes of operating, would permit the  knife
to pass over the neck of the bone without wounding the artery, and
afford an opportunity for the vessel  to  be compressed before the
 anterior flap is completed.   As the arteria profunda also  takes the
 same  direction as the femoral till it is at least an inch and  a half be-
 low the trochanter minor,  the knife need not interfere with it.*
   Lisfranc  adverts  to  four  methods of finding the  hip-joint with
 precision in the living body.
    1st. From the anterior  superior spine  of the ilium make a per-
 pendicular mark,  fifteen lines long,  and the external  and  front part
 of the joint will lie  exactly  six lines to the inner  side of the lower
 termination of such mark.
   2d. From  the  anterior inferior spine  of the ilium, draw a perpen-
 dicular line, about six lines in length, and its termination will corres-
 pond to the upper part  of the joint.
    3d. If from the end of a transverse line, drawn  from the spine
 of the os pubis outwards, rather more than two inches and a quarter
 long, another line, a quarter of an inch  in length, descend at a right
 angle, it will  also pass over the joint.
    4th.  If,  from the outer, front, and upper part  of the trochanter,
 a  line half an  inch  long, be drawn perpendicularly upwards, and
 then another  line be drawn from the end of the first at a right angle
 inwards to the extent of an inch, the second one  will extend  to the
 head of the femur some little allowance being  made  for  the  differ-
 ence in the length and  direction of the neck of the femur in  differ-
  ent subjects.
* Malgaigne, Manuel de Med. Operatoire, p. 356. 
484
OPERATIONS.
  When the patient is in the recumbent posture, the tuberosity of
the  ischium projects about fifteen lines in front of the acetabulum.

      METHOD OF  LISFRANC WITH  TWO LATERAL FLAPS.

  First Stage.—The femoral artery is to be compressed as it passes
over the os pubis.   When the left  limb is to be removed, the sur-
geon is  to stand on the outer side of  it, while tbe  patient  is in the
recwmbent posture, with  the tuberosities of the ischium projecting
a little way beyond the end of the operating table.   If possible, the
limb itself is to be in  the middle position  between  adduction and
abduction; and the anatomical points, above specified, in relation to
thejoint, are to be well  recollected,  and  especially the directions
for  ascertaining  the precise situation  of its  anterior and  external
part.   At this place a long, narrow, but strong, sharp-pointed knife
is introduced, with  its edge  directed towards the apex of the great
trochanter.   The point having passed down close to the bead of the
femur, is to be carried round its outer side;  but, in proportion as
the  point enters further,  the handle must be inclined  outwards and
upwards, so that the point may pass out a few lines below the tuber-
osity of the ischium.   In order to fulfil this object, an assistant, or
the surgeon himself, should grasp and draw outwards the integuments
and muscles at the  back  of the limb.   Tbe transfixion having been
completed, the knife, with the edge still turned towards the apex of
the great trochanter, is  to be carried downwards  along the bone,
with a sawing motion, rather than  by  pressing muchvivpon  it, and
thus the external flap is formed.   This is to be immediately raised,
and such arteries as pour out much  blood compressed with the fin-
gers of the assistants, and tied  before  the rest of the operation is
proceeded with.
   Second Stage.—The  surgeon, with his left hand, then pushes the
soft parts inwards,  and introduces the  point of the knife below the
head of the femur, on the inner side of the neck, with the edge turn-
ed directly downwards.   Then the knife is to be carried  under the
neck of the femur, and pushed through the limb, without  touching
the bones of the pelvis,  at the  posterior and  superior  angle of the
wound.   Being now  held perpendicularly, it is conveyed two in-
ches downwards close to  the femur, avoiding, however, the tro-
chanter minor; and, as soon as the incision  affords room enough,
an assistant compresses the femoral artery  contained in the flap, and
the second stage of the operation is concluded by giving to this in-
ternal flap a length corresponding to the external.
   Third Stage.—The surgeon now  lakes hold of  the femur with
his left hand, and  with  a scalpel freely divides the orbicular liga-
ment at the inner side of the joint,  which being done, the  ligamen-
tum teres can easily be reached with  the  end of the knife, and cut
through.   Lastly,  the knife, held perpendicularly, is to be applied 
BECLARD's  METHOD.
485
to tbe inner side of the joint,  and carried from within outwards, so
as to cut through the rest of the orbicular ligament, and any  fasci-
culi of muscular fibres not previously divided.
   When the right limb is to be removed, the surgeon must stand by
the side of the  patient's trunk, in order to be able to operate with
the right hand.
   The advantages  of  Lisfranc's  method  are,  the quickness with
which it is executed, as 1  have  often demonstrated at University
College on the dead subject;  and its occasioning as little loss  of
blood as possible, the  arteries of the external flap being tied before
the internal one is  formed, and the  femoral artery taken hold of by
an assistant before  the  latter  flap is  completed.   The  flaps meet
well, and the extensive wound admits of  being  completely closed,
which may be accomplished with straps of adhesive plaster, aided,
if necessary, with three or four sutures.
   When, owing to the state of the  injury, or disease,  a  sufficient
flap cannot be saved on one side of the limb, the flap on  the other
side is to be made  proportionably longer.

                      beclard's method.

   The  thigh being held in the state  of half abduction, the scrotum
carefully raised, and the artery compressed, as it passes over the os
pubis, the surgeon, standing on the outside of the  limb,  feels for
the great trochanter, and introduces the point of the knife one inch
above it.   The edge is to pass as close as  possible to the  bone, at
the inner side of  the limb, its point  being  pushed  out in a situation
precisely opposite the  place  of its  entrance.   The knife is next
carried  down,  close to the anterior surface of the  bone,  to  rather
more than three inches  below the joint where the anterior flap is to
end.   Then the capsule, and  any soft parts covering it,  are to  be
divided transversely, and the  ligamentum teres cut through.   The
knife is next to pass, from before backward round the head of the
femur to the back  of this bone, down which it is to  be carried  to
the extent of about three inches below the joint.   Thus the poste-
rior flap is completed.*  According to Velpeau, Beclard made the
anterior flap, after  the completion of the posterior one.
   Mr.  Liston also prefers anterior and posterior  flaps.    " Trans-
fixion, with  a  knife  proportioned in size to the dimensions of the
limb, is made horizontally, the instrument being passed in a some-
what  semicircular  direction,  so as to include as much  of the soft
parts as  possible;  and  an anterior  flap is made by cutting dovyn-
wards.   During the passage of the knife across the joint, the assist-
ant rotates the limb a little, so as to facilitate the bringing of the in-
strument out, with its point well inwards.   In the left limb, the ro-
» J  F. Malgai<»ne, Manuel de Me"d. Operatoire, p. 868.
               41* 
486                      OPERATIONS.
tation will be inwards; in the right, outwards.  After the formation
of the flap, the assistant abducts  forcibly, and presses downwards;
the joint is opened,  the round ligament  cut, the  capsule  divided,
and the blade of the knife placed behind the head of the bone and
the large  trochanter; and the posterior  flap is then made rapidly.
After transfixion for the superior flap, and when the sawing motion
has advanced but a little way, the compressing assistant shifts  his
hands into the incision, immediately behind  the back of tbe knife,
and so obtains a firm grasp of tbe femoral artery  previously to its
division."*   As  this  cannot  now  bleed, Mr. Liston secures the
other arteries first.

                  AMPUTATION  OF  THE LEG.

   In the thigh, amputation is performed as low as the case will al-
low.    In the  leg,  the common  practice is to  make the incision
through the integuments sufficiently low to enable the operator to
saw  the bones, about four inches below the lower part of the patel-
la.  This is necessary in order to  have a sufficient  surface in front
of the limb for the application of a wooden leg, and not to deprive
the stump of that power of motion, which arises from  the flexor
tendons of the leg continuing undivided.
   The tourniquet, or pressure with the thumb, should be applied to
the  femoral artery, two thirds of  the way down the thigh, just be-
fore the vessel perforates the tendon of the adductor muscle.   The
operator is to stand on the inside of the leg,  in order to be able to
saw both bones at once.   The leg being properly held, the integu-
ments should next be drawn upward by  an assistant,  while the sur-
geon, with one quick stroke of the knife, divides the skin complete-
ly round the limb.
   Having made a circular division of the integuments, the next ob-
ject is to preserve skin enough to cover the front of the tibia and the
part of the stump corresponding  to the situation  of the  tibialis an-
ticus, extensor longus pollicis, and other muscles between the tibia
and fibula, including those covering the latter bone; for, throughout
this extent, there are no bulky muscles which can be made very ser-
viceable in covering the end  of the stump.   But, on the posterior
part of the leg, the skin should never be detached from the gastro-
cnemius muscle, which, when obliquely divided, will, with the so-
leus, here form a sufficient mass for  covering the stump.   Hence,
 as soon as the skin has been separated on the anterior and  external
 side of the leg, the surgeon  is to place the edge of the  knife in the
 incision of the integuments,  and cut in the Alansonian way through
 the  muscles of the calf, from the  inside of the tibia, quite to the
  * See Liston's Elements, Part iii. p. 396.  For a description of other  methods,  I
refer to my Dictionary. 
AMPUTATION  OF THE  LEG.              487
fibula.   Then tbe flap, formed by the calf of the leg, is to be held
back by the assistant, while the surgeon completes the division of the
rest of the muscles, together with  the  interosseous ligament, by
means of the catling, or any narrow double-edged knife.
   In amputating below the knee, particular care must be taken to
cut every fasciculus of muscular fibres, before  the saw is used.
Every part being divided,  except the bones, the  soft  parts  are to
be protected from  the  saw by a  linen retractor,  made  with three
tails, one  of which is to be drawn through the interosseous space.
   The principal  arteries,  requiring  ligatures, will be the  anterior
 and  posterior  tibial,  and  the peroneal.   The sharp  anterior  edge
 of the tibia, if likely to injure the integuments, may be removed by
 means of  pliers, or a fine  sharp saw.
   In dressing the wound,  the soft parts preserved  for covering the
 bones should be brought together, so as to  make  the line  of  their
 union not  transverse, but obliquely perpendicular, the lower end of
 it being more external than the upper.  Thus the tibia and fibula
 may be effectually covered, without the strips of adhesive plaster for-
 cibly pressing the skin  against  the  sharp  edge of  the  tibia.   The
 strap of plaster,  on which most  dependence is placed, should go
 over the centre of the  stump, at the  point corresponding to  the in-
 terosseous space.

 FLAP-AMPUTATION  OF THE LEG BELOW  THE  TUBEROSITY OF
                           THE  TIBIA.

   If the  right leg is to be  removed, the operator places himself on
 its inner side,  and grasps the lower part  of the limb with   his left
 hand, while an assistant supports the foot.  The knife  enters over
 the outer  side  of  the fibula,  and  is carried upwards along that  bone
 for an inch and a half  or two inches.   The incision is then  extend-
 ed across the front of the  leg in a semicircular  direction;  and as
 soon as the knife reaches  the inner  part of  the tibia, transfixion  is
 performed, the point being pushed  along the posterior surface of
 the two bones, and out at the upper  angle of the  incision  oyer the
 fibula.   The knife  is then carried downwards, and a posterior flap
 formed of sufficient size to cover the stump.
    All this is effected  by uninterrupted sweeps of  the knife, that is,
 without ever removing its  point  from the track of the  incision.
 With the same knife,  the integuments  on  the forepart of the leg
 are then  dissected up  a little way, so as  to form a small semilunar
 flap.   The muscles in the interosseous space are  next divided, and
 the knife is carried round the bones  for the division of any of the
 the parts yet  uncut.   Mr. Liston prefers sawing the bone in the
 perpendicular direction.   Before laying down the flap, he removes
 the sharp anterior  ridge  of the tibia with the  cutting pliers.  In
 operating on the left leg, transfixion is commenced  by passing the 
488
OPERATIONS.
knife close behind  the tibia,  and  its point is  afterwards  pushed
through the preliminary fibular incision.*   The most simple plan is
first to form  the posterior flap by transfixion, and then to make the
anterior flap, and divide the muscles in the interosseous space.  The
anterior flap should be somewhat longer than usually made, so as  to
cover the tibia better, and render it unnecessary to have a posterior
flap of great length, which always  proves a source of profuse sup-
puration.

                  AMPUTATION OF  THE  ARM.

   The structure of  the  arm bears a  great  analogy to that of the
thigh.   There is only one bone round which the muscles are ar-
ranged, the deep ones being  adherent  to  it, while the  outer one3
extend from  their origins to their insertions, without being attached
to it.   The first are the brachialis internus, and the two short heads
of  the triceps;  the others are, the long portion of the latter muscle,
and the biceps.   Hence amputation of the arm  may be performed
in a very similar manner to the same  operation on the thigh, unless
it be necessary to remove the limb above  the  insertion of  the del-
toid muscle.
   The patient may  either sit on a  chair, or lie near  the edge of a
bed, and an  assistant is to hold the arm in a horizontal position, if
the state of the limb will allow it.  The pad of the tourniquet is to
be applied to the brachial artery, as high as convenient.   The as-
sistant is then to draw up the integuments, while  the surgeon makes
the first circular incision.  In this  operation, the skin need only  be
detached from  the muscles to a very moderate extent,  for there is
no risk of not having sufficient  flesh and  integuments to cover the
bone.   Here, indeed, some  surgeons imitate Dupuytren,  and  cut
at  once through trie skin  and loose portions of muscle.  If the or-
dinary method be followed,  the biceps may be  divided first, and,
after the retraction  of this  loose  muscle,  the  brachialis internus,
which is fixed to the bone, may  be  cut through and separated a little
upwards from the bone.
    The triceps may next be cut through  at once, by one sweep of
the knife, with its edge turned obliquely  upward.   The other pro-
ceedings do not require description, after the account already given
of what is necessary in amputating the thigh.
    When it becomes indispensable  to amputate the arm high up,  the
 subclavian artery is tobe firmly compressed, as  it passes  over  the
 first rib, by  an assistant, who can effectually accomplish this impor-
 tant object with his thumb,  or  by pressing the  vessel from above
 the clavicle with the handle  of the key, covered with soft materials.
 When the bone can be sawn through below the insertion of the pec-
• See Liston's Elements of Surgery, part iii. p. 391. 
AMPUTATION  OF THE ARM.
489
toralis major,  there  is no  peculiarity  in the method of operating.
But, if it be necessary to take off the limb still higher up, the circu-
lar incision is not  advisable.   Here some surgeons make  a flap of
the deltoid muscle,  and commence with making an incision corres-
ponding to its margin in shape and situation.   Then the muscle is
to be detached from the bone beneath, so  as to form the flap, which
is to be  turned  up.  The  operation  is now  finished  by cutting
through the other soft parts, from one  side of the base of the flap to
the other.
   Instead of making a short stump, when  the arm must  be taken
off high up, Larrey prefers amputating at the shoulder-joint.  He
says, that, if the humerus is sawn through higher than the  insertion
of the deltoid muscle, the stump becomes  retracted towards the arm-
pit by the pectoralis major  and latissimus dorsi;  the ligatures on
the vessels irritate the axillary plexus of nerves ; great pain and ner-
vous twiches are excited; tetanus  is frequently  brought on; the
stump is affected with considerable swelling; and at length, anchy-
losis of the shoulder follows.*
   According to Mr. Guthrie,  when amputation is  attempted at the
insertion of the pectoralis major, the bone will  mostly protrude af-
ter a few dressings; and a disagreeable  painful stump be  tbe con-
sequence.   The artery is also liable to retract into  the axilla, where
it cannot  readily be taken  up.   Here, instead of amputation at the
shoulder-joint, he recommends the following operation:—" Two in-
cisions of a similar shape are to be commenced, one or two fingers'
breadth below the acromion, as the case  may require; the point of
the inner one, instead of ceasing, as in  the operation of the  shoulder,
a little  below  the pectoral muscle,  is to  be carried directly across
the under part, to meet the point of the outer incision;  so that the
under part of the arm is cut by a circular  incision; the  upper, in
the same  manner as in the operation at the shoulder.   These inci-
sions are only through the  skin  and  cellular membrane,  which have
liberty to retract, but are not to be turned  up.   The  deltoid and
pectoralis major are then divided close  to the inner incision, and the
opposite portion of  the deltoid, with the long head  of the  biceps on
the outside, to the extent of the outer incision.   A half-circular cut
on the under part, in the line of the skin down to the bone, clears it
underneath,  and  shows the artery retracting with  its open mouth,
which is at this moment advantageously pulled out be a tenaculum,
and  secured."   The flaps are then  held asunder, and the bones
sawn, &c.f

      AMPUTATION OF  THE  ARM  WITH  LATERAL  FLAPS.

   One  of the quickest methods of removing  the arm is Dupuy-
* Mlmoires de Chirurgie Militaire, t. iii. p. 53., &c.
t Cuthrie on Gunshot Wounds, p. i'40. 
490
OPERATIONS.
tren's operation,  in which he  cut the integuments and  muscles to-
gether, separated  the muscular fibres  upwards from the bone, and
then applied the saw.   Another expeditious method, and one which
also forms an excellent stump, is amputation with  the  lateral  flaps,
which may be adopted at any point below the insertion of the del-
toid muscle.   The limb  is held up from the side at  a convenient
height,  and the point of the  knife, with the edge directed  towards
the elbow, is  introduced  directly down  to the bone, either at  the
front or posterior  part of the limb, and, as nearly as possible in the
middle of it.  As soon as the point of the knife touches the bone,
it is to be  conveyed very  closely round  it, till the position of the
blade is such, that the point can be pushed through some part of the
central line of the limb, directly  opposite to the place where  the
knife first entered.  The transfixion having been completed, a flap
is formed by cutting rapidly  dow-nwards, with a sawing motion of
the knife, inclining its edge downwards or upwards, according as it
may be  the internal or external flap  which is being  formed.   As
soon as one flap has been made, an assistant is to hold it out of the
way while the surgeon  makes the other.  " The knife is again en-
tered, about half  an inch below the commencement of the first in-
cision, and by inclining the handle, the point is brought round the
bone, and  made to appear  on the  opposite side also of the first in-
cision."*  When it is  the external flap which is being formed, this
part of the operation is facilitated by pulling the soft parts outwards
with the  left hand.   Lastly,  the knife is carried  rapidly round the
bone, so as to divide any of the adherent  muscular  fibres yet un-
cut, and then the  saw is to be used.
   I have sometimes tried  this method in University College Hos-
pital,  and find it  has  the advantages  of expedition and of making
a good  stump.   The hemorrhage was effectually commanded by
the pressure of the fingers on the brachial artery just below the ax-
illa.  The projection  of nerves  is most likely  to be avoided by
giving the  edge  of the knife rather  a sudden turn outwards,  after
the proper  length of flap has been secured.

                AMPUTATION  OF THE  FOREARM

Should  be  performed as  low as the case will allow.   The tourni-
quet is to be applied with its  pad on  the  brachial artery, at the in-
ner edge of the biceps muscle, or the flow of blood  through that
vessel may be commanded by an assistant making pressure on it.
While one assistant holds  the  hand,  another grasps  the  forearm,
above the place where the  first circular wound is to  be made, and
draws up the integuments.   After the amputating knife  has  been
carried round the limb, the skin is to  be  detached from the fascia.
• See Liston's Elements, Part iii. p. 383. 
AMPUTATION  OF THE  FORE-ARM.
491
a little way upward.  The muscles are then to be divided oblique-
ly upwards with the same knife, which, if not too broad, is also  to
be employed for completing the division of the parts,  between  the
radius and ulna.   If the blade be wider than is convenient  for this
purpose,  the catling, or any narrow  double-edged  knife, must  be
used.   The retractor is to be applied, and the bones sawn,  with
the hand in a state of pronation.
   In general,  only four vessels require  ligatures, viz. the radial,  ul-
nar, and two interosseous arteries.
   Larrey deems  it advantageous to take  off the  forearm  in  its
fleshy part,  notwithstanding  the  nature  of  the disease, or injury
would  admit  of  the  operation   being  done  towards  the wrist.
However, as  I have amputated  several  forearms  near  the wrist,
and  the stumps healed in the best way, I see every reason for still
adhering to the old good maxim  of saving as much of the limb as
possible.   The cause  of  the bad   success,  which  many of the
French surgeons have had after amputating in the tendinous part  of
the forearm, has been  correctly referred  by Mr.  Guthrie  to  their
prejudices against the attempt to heal the stump  by the first  inten-
 tion.*

    FLAP-AMPUTATION  OF THE  FOREARM, AS PRACTISED BY
                     KLEINf, LISTON,  &C.

   The surgeon, with his left hand, grasps the wrist, and  places the
forearm in  the middle state  between   pronation  and  supination.
 Supposing the  right forearm is  to  be  removed,  the  knife, held
 perpendicularly, enters over the centre of the radius, and  its point,
 after reaching the bone, is inclined inwards, and,  being conveyed
across close to the palmar surface of it and the ulna, completes the
transfixion at a point opposite that of its entrance.   By cutting  ra-
pidly downwards and inwards, the first flap  is then  formed.   The
knife is again  introduced over the radius, just below the upper part
of the first  wound, and conveyed across the  opposite side of the
bones until its point emerges at the other extremity of the first inci-
sion.   The second flap is then made.   The two flaps being retract-
ed,  the knife is carried round the bones,  and passed freely between
them, after which  they  are  to  be  sawn perpendicularly  with the
forearm in  the same position.   Amputation  of  the forearm,  by
means of the circular incision, may be performed, with tolerable ex-
pedition,  and, in my own practice, the  stump has usually healed  up
with facility, so that  I  am rather in favor of it; though which op-
eration is here  preferred, may be a point of no very great impor-
tance.
  * On Gnnshot Wounds of the Extremities, p. 370.
  t Practisohe Ansichten der bedeutendsten Chir. Operationcn, p. 45. ltes Heft, 4to.
Stuttgart, I8lt». 
492
OPERATIONS.
              FLAP-AMPUTATION  AT THE  WRIST.

  If the hand be extended back, the angle which it forms with the
forearm  will denote the  radio-carpal articulation, which is one line
below the transverse projection of  the radius, and about five above
the cutaneous fold between the hand and forearm.   The  middle of
the joint may also be found two lines and a half above a line, drawn
across  from the  point of the styloid process  of the radius to that of
the ulna.   The knife  is to pass across from one styloid process to
the other, and the  anterior  flap be  formed.   The hand being then
put into the prone position,  the knife is introduced at one of the up-
per angles of the first incision, transfixion performed, and a posterior
semilunar  flap made.   The operator is then  to make an incision
below  the styloid  process of the radius,  and  with a  semicircular
sweep of the knife corresponding to the direction of the articulation,
all the ligaments are  to be  cut, and the operation  finished.   Ac-
cording to Malgaigne, this method, which is followed  by Lisfranc,
is a quick and showy one, but less advantageous in its results, than
amputating at the  wrist with a circular incision.

            AMPUTATION  AT THE SHOULDER-JOINT.

   The loss  of  blood is to be prevented,  by compressing  the sub-
clavian artery from above the clavicle.  The choice  of the method
of operating must be determined by the  state of the soft parts cov-
ering the joint.

             LA FAYE's  METHOD  WITH  ONE  FLAP.

   With a large common bistoury, a semicircular incision is to be
 made, with its convexity downward, across the integuments  cover-
 ing the  deltoid muscle, about  four inches below  the acromion.*
 The skin is not to be detached; but the surgeon is to proceed im-
 mediately to raise the muscle from the bone, quite  up to the joint.
 If the  circumflex  arteries  bleed considerably, they are now to be
 tied,  before the  operator  proceeds further.   Then the surgeon
 should cut the tendons passing over the joint, and also the capsular
 ligament, so as to be enabled to dislocate the  head of the bone.  With
 one stroke of the amputating knife, he is  then to divide the skin,
 muscles, and other  parts  underdeath the joint, and thus  complete
 the separation of the limb.   Then  the  axillary artery is to be in-
 stantly  taken hold of with  the forceps or double tenaculum, and
  * The horns of the semicircle, if I may use the expression, are to extend upward
along the anterior and posterior margin of the deltoid muscle. 
           AMPUTATION AT  THE  SHOULDER-JOINT.        493

tied.   The flap of  the deltoid muscle is next to be laid down, and
its edge will then meet the lower margin of the wound.
   The preceding method is one of remarkable simplicity, as I can
truly affirm, not only because  I have tried it myself, in three instan-
ces, but seen it performed on  several occasions  by other surgeons.
The last case,  in which I was requested to give my assistance, was
a  patient of Dr.  Blickes', of Walthamstower the operation was
practised as a last resource for a spreading mortification of the arm
from external violence;  and though the man  survived  only about a
fortnight, nothing could be more easy than the operation itself, and
it  was  impossible to have had a better stump.
   In order to make a flap  of  the deltoid  mu=cle, some operators
prefer  first pushing  a catling,  or long, straight, double-edged knife,
through this muscle near the joint,  and next  cutting downwards,
they detach as  much of the flesh  from the bone as  they consider
necessary; the flap is then turned up; the tendon of  the Jong head
of the  biceps and other  muscles passing over ihe joint are divided;
the capsular ligament  is cut; the head of  the bone disarticulated;
and the operation finished, by passing the knife downwards between
the glenoid cavity of the scapula and the head of the humerus, and,
with one stroke, dividing all the parts towards the axilla.

          DUPUYTREN'S  METHOD  WITH  ONE FLAP.

   The arm being raised from the side,  the deltoid muscle is grasp-
ed with the  left hand, and  a double-edged knife passed through its
base, directly below the acromion, and  carried down  close  to  the
outer side of the humerus, so  as to form an external flap of suitable
extent.  This  is to be held up by an assistant, while the humerus
is moved  near to  the side, in order  to incline those  tendons out-
wards, which are inserted  near the head of the bone, and which are
now to be divided,  beginning with the posterior ones, which are more
easily  got at, on account of the greater  space between the acromion
and the head of the humerus, than between the latter part and  the
coracoid process.  The fibrous tissues, connecting the head of the
bone  to the acromion, must  likewise be  divided, after which the
operator takes hold of  the arm with his left hand, dislocates the
head of  the bone outwards,  and  passes the  knife inwards for the
purpose of dividing the soft parts in  that direction, where the prin-
cipal nerves and  bloodvessels  are situated.   At this moment the
assistant, who  holds up the external  flap, pinches up the  soft parts,
by placing the thumb of his  right hand on  their bleeding surface,
and the four fingers under the axilla, and thus compresses the artery.
The operator, now having no fear  of hemorrhage,  completes the
division of the parts on a level with  the attachments of the  pectora-
lis major and  latissimus  dorsi  to the  humerus.  The flap is then
brought down  and  united by the first intention,  This is the opera-
   yoL,  n.                     42 
494
OPERATIONS.
tion of La  Faye and  Ravaton  simplified, and perfected.   As M.
Malgaigne observes, by directing the edge of the knife inwards, the
capsule of the joint might be laid open by the first stroke.

            LISFRANC's METHOD  WITH TWO  FLAPS.

   In  this operation, the surgeon is particularly to remember that,
between the acromion  and  the coracoid  process, there is a triangu-
lar space, bounded behind  by the clavicle, and where the arch over
the joint is simply fibrous.
   1st.  Supposing  the left arm  is about to be removed, it is to be
raised outwards nearly to a right angle.   The surgeon stands behind
the patient, and grasps the cushion of the  shoulder  with his left
band, putting  his thumb on the  humerus, and the index  and middle
fingers on  the above-mentioned triangular space.   Then taking a
double-edged  knife, eight  inches  long,  he introduces it parallel  to
the humerus,  at the outer side of the posterior margin of the axil-
la, in front of the tendons  of the latissimus dorsi  and  teres major,
with the blade in such  a position that its  flat part forms  with the ax-
is of  the shoulder an angle of 35 deg.,  while its upper edge is turn-
ed a little forwards.   The knife is carried up along the posterior
and external side of the humerus, till it arrives under the acromion:
now its point  is to be depressed, and its handle raised, to the dis-
tance of two  or three  inches from the arm, till it forms with the axis
of the joint an angle of 30 or 35 deg.  Then the surgeon is to press
directly on  its point, which will pass through the joint, and  come
out in front of the clavicle at the inner  side of the acromion, at the
triangular space above described.   Next,  while the handle is  kept
nearly motionless, the end of the blade is  carried round the bead of
tbe humerus from within outwards, and from below rather upwards;
and  directly the knife  is  clear of the acromion and head of the bone
it is carried boldly downwards along the  external side  of the arm,
and the posterior flap  is formed, about three inches in length.
   2d.  The operator,  keeping his hand depressed, and cutting from
 the heel to the point,  slides the knife from behind forward at the  in-
 ner side of the head of  the humerus, depresses the handle till it is
 perpendicular to the  horizon,   directs an  assistant to compress  the
 artery, and thus completes the  anterior flap.
   When the  right arm is  to be amputated, the surgeon may either
 plunge  the knife into the triangular space,  above indicated,  and
 bring its point out in front of the  posterior margin of the axilla; or
 else he  may stand at first  behind the patient to  make  the posterior
 flap, and  then move to  the patient's  side  to finish   the anterior
 one-
   No method is more expeditious than the foregoing.  In the first
 stage, the surgeon cuts at once the tendons of the latissimus dorsi,
 teres major and minor,  supra and  infra spinatus, a portion  of  the 
AMPUTATION  AT THE  SHOULDER.            495
deltoid, one half of tbe capsular  ligament, tbe subacromial fibrous
tissue;—in a word, almost all  the parts attached  to the hume-
rus,  the head of which can be  immediately afterwards disarticu-
lated.                                    J
   When the patient is  under the age of fifteen,  M.  Lisfranc, re-
collecting the cartilaginous state of  the acromion, recommends an-
other method with  two flaps, the peculiarity  of  which consists in
directing the knife,  so  as to remove the cartilaginous  extremity of
that  part of the  scapula.  But,  as  M.  Malgaigne justly  remarks,
the latter expedient,  by lessening the prominence  of the shoul-
der,  would be likely to increase  the  deformity  resulting  from the
operation.

                   LARREY's  OVAL  METHOD.

   An  incision   is  begun at the acromion, and carried down to an
inch below the level of the neck of the humerus, dividing  the  in-
teguments and the deltoid,  down to the bone, into two equal por-
tions.  An assistant then draws up  the skin of the arm towards the
shoulder, and the operator makes two oblique incisions, which com-
mence from the  termination of the  first,  an  inch below the acro-
mion;  one extending to the anterior border of the axilla;  the other
to its  posterior border;  and  both   prolonged so  as  to divide
the pectoralis major and latissimus dorsi very  close to their  in-
sertions.
   The cellular  connections of the  two flaps to  the bone  are next
divided, and the flaps  themselves held by an assistant, who, at the
same time, stops the bleeding from the circumflex arteries by the
pressure of his fingers.  The joint is now exposed, and, with  one
stroke of the knife, over the upper  semicircle of the  head of the
humerus, the capsule and tendons are cut  through.    The  head of
the humerus  is then dislocated; and the knife  being conveyed to tbe
inner side of the bone, the flesh is detached from the latter.  Finally,
while an assistant compresses the axillary artery, the surgeon com-
pletes  the operation by cutting transversely through  the  remainder
of the skin and  muscles, on a level with the  lower ends of the two
oblique incisions.
   The arteries  having been secured, there are,  strictly speaking,
no flaps; the wound, on being closed,  presenting, as after all oval
amputations, merely the appearance of a  straight line.

         CIRCULAR AMPUTATION  AT THE  SHOULDER.

   Garengeol, Alanson, Graefe, Sanson,  and Cornuau, are record-
ed amongst its patrons.  A circular incision   is  made through the
integuments, three  inches and a half, or four  inches below the acro-
mion.  The skin is retracted, and the deltoid cut obliquely from be- 
496
OPERATIONS.
low upwards, so as to expose the joint.  With another  stroke of
the knife, the tendon of the  biceps and  the upper  part of the cap-
sule are divided.   Tbe bead of tbe humerus is then dislocated;  the
knife carried to the inner  side of the bone; the  muscles separated
from it in that direction;  and, while an assistant compresses the ar-
tery, the soft parts towards tbe axilla are cut on a  level with those
on the outer side of the shoulder.
   M. Sanson makes his  first  incision one  finger-breadth  from
the acromion and  unites the anterior with the posterior wound: in
fact, as  M. Malgaigne  remarks,  the result is the same as that of
Larrey's mode,  divested of the upper incision, but more difficult of
execution.*
   Excellent as some  of  the preceding operations are, the exclusive
preference to any  one of them, as declared by some writers,  has
been made wiihout reflecting,  that, in many of the examples in
which amputation at  tbe shoulder is indicated, the  deltoid muscle is
much lacerated, or more or less of it actually torn away.   Under
such circumstances, a sufficiency  of  soft parts for making the flaps
must be saved, from whatever quarter they can be obtained, wheth-
er the external, or tbe anterior, or the posterior side of  the should-
er.  Sometimes a flap can be obtained, indeed, only  at the  poste-
rior, or the anterior side, as every experienced  military surgeon is
well aware of.

            AMPUTATION  OF  PARTS OF THE HAND.

   As Dr.  Macfarlane correctly  observes, the propriety of some-
times attempting to save  a portion of the foot, or  hand, in cases of
injury, or disease, by having recourse  to  partial  amputation,  has
been long known,  and acled upon  both in this country and on  the
Continent.  If the thumb and little finger can be preserved,  or  a
portion  of  either of them, the advantage to the patient will be con-
siderable.  In University College Hospital, we have had many pa-
tients, whose hands were so badly shattered and crushed by machin-
ery, that, at first, it seemed as if  it would have been  impossible to
save any part of them.   Yet the experiment of partial amputation
having been made, very useful  portions  of the  hand were  saved.
Thus, the  thumb,  and one or two fingers bave sometimes been  sa-
crificed and the rest of the hand saved; or, what has been still bet-
ter, the thumb and one  or two fingers have been saved, though the
other fingers, and even some of the  metacarpal  bones  have been
unavoidably removed.   WTith such facts before  him, let every  sur-
gical practitioner pause a little, before he sanctions so great a, muti-
lation as that of removing the whole hand.
* See J. F. Malgaigne, Manuel de Medecine Opt'ratoire, pp. 329—334. 
                AMPUTATION  OF  THE  FINGERS.            497


AMPUTATION   OF  THE TWO  LAST  PHALANGES  OF  THE  FIN-
                             GERS.

   These phalanges, though  but loosely confined in their respective
places by the  anterior ligament, and behind by the extensor tendon,
are closely retained in it by the lateral ligaments.   Hence, in order
to open the joint freely, it is the latter, which require division.   The
line of the articular interspace, as M. Malgaigne remarks, has near-
ly a transverse direction, and in the articulation, of the first with the
second phalanx, is situated on a level with the cutaneous fold on the
palmar side of the finger;  while, over the articulation of the second
phalanx  with  the  third, the articular interspace is  half a line below
the cutaneous fold.
   Lisfranc's  first Plan.—In removing the last phalanx, the oper-
ator takes hold of it with his thumb  and forefinger, and bends it to
an angle of  45° .   There are then  three guides to the articular in-
terspace.   1.   At the back of the joint a conspicuous wrinkle of the
skin:  the line  of the articular interspace is  half a line below it.   2.
If this  wrinkle be wanting, the  dorsal  prominence  caused  by the
flexion is to be noticed, and the  incision made  half a line below it.
   3.  The  termination of the furrow of the palmar  surface  is  seen
on  each side  of the  joint: half a  line below this, the articulation
will be found.    The heel of a straight bistoury is to be placed per-
pendicularly  on the skin over the left extremity of the articular in-
terspace, and  a small semicircular flap is formed by cutting towards
the right side  of the  finger.  This  first stroke will  frequently lay
open  the ligament at the  back of tbe joint.  The next  thing is to
divide the lateral  ligaments.   In cutting through the  left one, the
knife  is to be held perpendicularly to the axis  of the last phalanx,
with the handle nearer than the blade to the operator, and the  edge
also slightly inclined towards him.   In this way, the incision is ac-
commodated to the disposition of the articular surfaces, and the lig-
ament is cut through  at the first stroke.   The knife is then applied
to the other side, and  the second lateral ligament divided in the same
direction, but  with the handle of the knife directed downwards, and
kept further from the  operator than the blade.   The joint  having
now been largely opened, the phalanx is to be placed in an extend-
ed position, and the knife, having been carried through the joint and
capsular ligament towards the  palm, is there brought out, a semi-
circular flap being formed of sufficient size to cover the end of the
bone.
   Amputation between the first and second phalanges is performed
in a similar way, except that the dorsal incision should terminate on
each side precisely at the extremity  of the palmar fold of the skin.
The surgeon,  as he is dividing the lateral ligaments, is to avoid cut-
ting the base of tbe palmar flap. 
498
OPERATIONS.
• Lisfranc's second Method.—All the fingers are to be bent, except
that which is about to be removed; and the hand is to be placed in
the supine position.   The  surgeon takes hold of the  phalanx with
the forefinger and thumb of his left hand.   A straight,  very sharp-
pointed knife, with the edge directed toward the extremity of the
finger is  introduced half a  line below the palmar cutaneous fold, if
it  is the third  phalanx which  is  to  be removed; but  exactly at
the base  of this fold, if it  is the second  phalanx.   The knife is
to pass closely across  the  palmar  and lateral surfaces  of the bone,
nearly to the heel of the blade, and then the edge is to be inclined
upwards, and a semilunar flap made.  The  knife is  next  applied
perpendicularly at the  base of the flap for the  purpose of cutting
the palmar  portion  of the  capsule.  But,  in  this  method,  it is
scarcely necessary  to divide the  lateral ligaments  separately, as
with a single  stroke,  the  knife may now  be  carried completely
through the  articulation, and the integuments divided, without mak-
ing any  dorsal  flap.   If the extensor tendon  should  project too
much, a piece of it should be cut  off with scissors.
   In general, no ligature is necessary, and tbe flap is to be retained
in its place with adhesive plaster.

AMPUTATION OF A FINGER AT THE METACARPAL  EXTREMITY.

   The articulation  is an enarthrosis with loose  ligaments; and the
articular prominence, or knuckle,  presenting itself when the finger
is bent, is formed  entirely by the metacarpal  bone, the  phalanx
playing on its inferior surface.   In the healthy state, the joint is us-
ually situated ten or twelve lines above the commissure of  the fin-
gers.
   Here amputation may be performed with two flaps; or the oval,
or the circular method may be adopted.   The  oval  method seems
to me the best.
   1.  The precise situation of the joint  having been  ascertained,
and the  phalanx bent, an  oblique incision is  to commence  three
lines beyond the articulation, and  terminate at  the digital commis-
sure.   The finger is  then to be extended, and  the  incision contin-
ued across the palmar side of it,  precisely in the direction of the
cutaneous furrow  between tbe finger  and the  hand.   The  knife
having reached the opposite digital commissure, the finger is to be
bent again,  and the incision extended so as to  rejoin its other  ex-
tremity two lines below the point  where it was begun.
   2.  The fingers are then to  be  strongly separated, the edges of
the wound dissected  up, the back of the  capsule opened, the later-
al ligaments  cut, and the operation concluded by detaching the fin-
ger on its palmar side.   The result is a linear cicatrix not at all en-
croaching on the palm- 
AMPUTATION  OF THE FINGERS.
499
AMPUTATION  OF ALL THE  FINGERS TOGETHER FROM  THE  ME-
                           TACARPUS.

  Tn this operation, it is useful to remember, that the  heads of the
second and fourth metacarpal  bones are really on the same level;
but that the third, which  supports  the middle finger, projects be-
yond them about one third  of a  line;  while, on ihe contrary, the
fifth, on which the little finger rests, is half a line shorter.*

                      LISFRANC'S  METHOD.

   1. In the right hand, the operator begins with making  a semicir-
cular incision, with  its convexity downwards, extending  from the
inner side of the head of the fifth metacarpal bone,  over  the points
where  the  fingers separate from  the  hand, and terminating on the
external side of the head of the second metacarpal bone.    The in-
teguments are retracted by an assistant, and, if necessary,  the sur-
geon dissects them a little way upwards.
   2. The  point of the knife is carried across the four joints, so  as
to divide the dorsal  ligaments; then  the lateral  ligaments  of  each
articulation are cut in  succession; and afterwards the palmar ones.
   3. Lastly, the knife is conveyed under the inferior surface oTthe
phalanges, and the palmar flap  formed, at first  towards  the  little
finger, the incision following the direction  of the cutaneous  furrow
of the  palm, and each finger  being lifted  up successively, as the
knife traverses the parts.
   The mode  of  proceeding is the same  for the left  hand, except
that the first incision is carried from the forefinger to the little finger.
   The same  method  will also  answer for the amputation of two
or three  fingers; an  assistant  holding  the others out of the way,
while the surgeon makes the dorsal flap principally with the point of
the knife, and begins and finishes the  incisions  on a level with the
articulations, which are to be opened.
   Circular Method; as practised by M.  Cornuau.—1.  The hand
being placed in  the supine position, the operator grasps the  four
fingers with his left hand, and makes in the  digito-pahnar furrow a
semilunar incision, successively  through the skin, vessels,  nerves,
and flexor tendons, down to the joint.   2.  The hand is then turned
prone, and the circular incision completed  on the back of the hand,
on a level with  the commissure of the fingers, dividing all  the soft
parts there, and penetrating into the articulation.   3. The heads of
the phalanges are now to be dislocated, and  the operation finished
by cutting through the lateral and anterior  ligaments.
• See J.  F. Malgaigne, Op. cit. p. 313. 
500
OPERATIONS.
                AMPUTATION OF  THE  THUMB.

  While the palmar aspect of the metacarpal bone of the thumb is
thickly covered, the dorsal surface  is almost subcutaneous.  This
bone is connected  by means  of loosish ligaments  to the  os trape-
zium, the articular surface of which is slightly concave from within
outwards.   By inclining it towards the metacarpal bone of the fore-
finger, its head may be made to project  externally.   On  the inner
side, the articulation is separated from that of the adjoining metacarpal
bone by an osseous ridge, one line in breadth, appertaining to the os
trapezium.   Lastly, the direction of the joint is oblique, or corres-
ponding to a line, which, when drawn from its outer side, would ex-
end to the root of the little  finger.
  In the ordinary mode of amputating the thumb and its metacarpal
bone from the trapezium, the thumb is placed in the  position of ab-
duction.   1. The  heel of a bistoury, held perpendicularly, with the
point  upwards, is then applied to the  middle  of the commissure,
and  an incision boldly  made downwards,  but gradually  inclining
towards the metacarpal bone of the  thumb, until the knife is stopped
by the trapezium.   2. Then the edge of the knife is to be convey-
ed into the  articulation in the direction  above  specified, and  the
head of the metacarpal bone luxated  towards  the palm.   3.  The
joinrhaving been thus cut through,  the edge of the knife  is revers-
ed, and carried along the radial edge of the metacarpal bone, so as
to form the  external flap, which should be as fleshy as possible, and
end a few lines beyond the articulation of the metacarpal bone with
the first phalanx.
   Some operators commence with  forming the external  flap, after
transfixion of the soft  parts at its base; and they then open the joint
from without inwards.

AMPUTATION- OF  THE THUMB  BY  AN  OVAL  INCISION.--SCOUT-
                      ETTEN's  METHOD.

   If the left thumb is to be  removed, the hand  is placed supine,
and a longitudinal  incision made through all the soft parts down to
the bone, beginning one line above the articulation of the trapezium,
and ending at the commissure  on the inner side of the first phalanx
of the thumb.   The  hand is now to be put into the prone position,
and  the incision prolonged  from the first over the dorsal surface,
precisely in the  direction of the upper cutaneous furrow, and  to the
point where the first incision began.   The muscles adherent  to the
whole extent of the external side of the bone are then to be  divid-
ed;  but, on  the palmar  side, only  at the upper half of the  bone.
 The joint is then laid open at  its posterior side, the metacarpal bone
dislocated outwards, and the detachment of the  thumb completed 
AMPUTATION  OF THE  FINGERS.
501
by carrying the knife close to  the inner  surface of the metacarpal
bone.
  In amputating the right  thumb, the first incision is made on  its
radial side.

AMPUTATION OF  THE  LITTLE FINGER AND  THE METACARPAL
                              BONE.

   The surface of the unciform bone, w hich receives tbe fifth meta-
carpal bone, is  concave from  behind  forwards, and slightly from
within outwards, so that a knife cannot be pushed at once complete-
ly across the joint; but it will pass very well  h,alf way  through it
from within outwards,  in the direction of a line, w hich would termi-
nate at the middle of the second metacarpal bone.
   1.  In order to  determine the place of the joint, the inner edge of
the metacarpal bone is  to be traced with the forefinger, till a promi-
nence is  felt  extending towards the palm.   This  is the unciform
process, and directly in front of it lies the articulation.  The articu-
lar interspace may also be felt on the  back of the hand  especially
when the bone is  moved.
   2.  The soft parts being grasped and drawn away from the bone,
a sharp  knife is introduced perpendicularly through  the  skin  and
muscles opposite  the  ulnar side of the  articulation, and  the edge
carried close to  the bone from behind  forwards.   Thus  a  fla*p is
made, which ends a little beyond the head of the phalanx.  3. While
an  assistant holds the  flap  out of  the way, the  surgeon dissects
the integuments  from  the  back,  of  the bone, leaving  untouched,
however, the extensor  tendon.  The soft  parts being drawn out-
wards,  the knife is carried along the other side of the bone, without
injuring the integuments on either side; and passing from  behind
forwards, it divides every thing  as  far as the  digital commissure.
4.  Its  edge is then applied  to the  inner  side of the articulation,
and enters half way into it  in  the direction above specified, and  in
being withdrawn   again  cuts through the dorsal ligament.   Then,
for the division of the ligament of the  two  metacarpal bones,  the
point is passed obliquely between the bones, with  the edge turned
towards the wrist.  All that  now  remains to  be  done, is to  cut
through the muscles and ligaments on the palmar side.'
   In  this country, the operation is  frequently executed  by cutting
through the interosseous space down to the os unciforme; forming
the flap;  and then cutting through the joint.
  * See Observations on Amputations of the Foot and Hand.  Med. Gaz. 1836. For
many of the foregoing directions, I am indebted to M. Malgaigne, whose little treatise
on the Operations is one of considerable merit. 
502
OPERATIONS.
         AMPUTATION OF METACARPAL BONES ALONE.

  The removal of injured, or diseased metacarpal  bones, without
their corresponding fingers, is sometimes  practised.   In compound
fractures or dislocations, when the injury  is confined  to one or two
of these bones, they may be excised, and a useful hand preserved;
but, when the injury is more  extensive, primary or secondary ampu-
tation will  generally be required.   In  one instance of disease  of
the metacarpal bone of the ring  finger, Dr. Macfarlane, of Glas-
gow, removed the bone by transfixing the metacarpal space on each
side with a French bistoury,  and cutting down from  the carpal ar-
ticulation to the first phalanx.  A useful  hand  was the result.   In
another instance,  he removed the  metacarpal bones of the  middle
and ring fingers:  he aimed at preserving  no flap, and divided  the
metacarpal spaces by cutting upwards  from the division of  the  fin-
gers, taking care  to avoid the extensor tendons of the fore and  lit-
tle  fingers,  which are apt to  be  divided on approaching the  carpus.
The metacarpal bones are readily dislocated from  the os  magnum
and os unciforme, and with a little force the parts were put in con-
tact.   After several months, a serviceable hand, with free motions
of  the fingers, was obtained.  Portions of these bones may be  ea-
sily cut out with  the aid of the cutting pliers.

            AMPUTATION OF PARTS  OF THE FOOT.

   I. Amputation of a single Toe.—The joints of  the toes resem-
ble those of the fingers; but the great toe has usually  three sesa-
moid bones, two  situated inferiorly, and  one internally;  while  the
second toe sometimes has one, and the little toe another.   The me-
thods of operating are here the same as on the hand; but that prac-
tised  With an oval incision is often preferred.*   Whether  in am-
putating the  great  toe, it  is most advantageous  to  disarticulate  its
first phalanx from the metatarsal bone, or to amputate in the conti-
nuity of the latter, is a disputed point.    The first method is object-
ed  to by some practitioners, because the head of the first metatarsal
bone is left,  forming too  great a projection, difficult to cover  pro-
perly,  and not well calculated to bear pressure.  On the other hand,
it is argued, that  the head of this bone constitutes one of the points
of  the tripod, on which the foot rests, and hinders the  internal side
of  the  foot from inclining  too much  downwards.   Hence,  it is
contended, that,  if possible, it ought to be preserved.   If the plan
of  amputating through the metatarsal bone be preferred, it is to  be
divided  either with a fine saw, or a strong pair of cutting pliers.
    II.  Amputation  of the five  Toes, according to  the  Method  of
* J. F. Malgaigne, Op. cit. p. 335. 
            AMPUTATION OF  PARTS OF  THE  FOOT.         503

Lisfranc.—Few accidents are likely  to  occur,  involving all  the
toes so severely as to require their removal,  without  the metatarsal
bones  being  likewise implicated.   Yet such cases have  been met
with, and, perhaps, as Velpeau observes,' they are more  likely  to
happen where the toes are frost-bitten and perish,  than  from any
other cause.   But,  even in  examples  of  this kind,  the  necessity
for the operation may sometimes be  superseded  by  allowing-  time
for the dead parts to be detached,  after which,  the end of the foot
will heal by the granulating process.   In the operation, it is to be
recollected, that the second metatarsal  bone  is one third of a line
longer  than  the first, which lies nearly on the  same  plane  as  the
third; the fourth is half a line behind the  latter; and  the  fifth still
more backward, so that, according to  the calculation of M. Mal-
gaigne, a transverse  line, drawn  from its articulation, would  pass
over the origin of the articular part of the first.
   1. A  semilunar incision is begun at the  inner side  of the head of
the first  metatarsal bone, and extended close to the line  at which
the toes leave the foot, to the external side of the fifth metatarsal
bone.   The flap is then dissected  up.
   2.  The point of the knife is then  passed from within  outwards
over the joints, so as partly to open them; after which, tbe lateral
ligaments are  to be cut.
   3.  The knife is next introduced under the phalanges of the great
and little toes, and then under  all the, phalanges at once.   The sur-
geon, with his left hand, now presses the  toes upwards toward the
instep, and carries the  edge and point of the knife from within out-
 wards, following the  track  of the furrow in the  lore part of the
 sole.  The arteries having been tied and the  wound  dressed, the
 foot is to be laid on its outer side,  in order thai  the  pus may more
 readily escape in the event of  suppuration.
   III. Amputation of the first Metatarsal Bone.—The posterior end
 of this bone has an  extensive articular  surface, in the direction from
 above downwards, slightly concave,  and  articulated  only with the
 great  cuneiform bone.   The articulation is strengthened  by four
 ligaments, an internal, a dorsal, a  plantar, and an interosseous liga-
 ment.    The  following method is  adopted  by  M. Lisfranc:—The
 operator takes hold of the integuments and muscles at the  inner side
 of the bone  with the thumb and fingers of his left hand, and draws
 them inwards as far as he can, in  order to  have a  flap of  suitable
 thickness.   The point  of a narrow straight  bistoury is then intro-
 duced perpendicularly  between the inner side of  the bone and  the
 soft parts,  two lines  behind  the articulation,  and a flap  formed
 along  the bone, terminating a little beyond  the joint  between  the
 metatarsal bone and the first phalanx.   From the base of this flap,
 which is to be held back by an assistant,  another incision  is made,
• Nouveaux EKm. de Med Oper.itoire, t. ii. p. 449. 
504
OPERATIONS.
which crosses the upper surface of the bone rather obliquely, and
terminates at the inner and upper part of the  articulation with  the
first  phalanx.   The knife is then carried between the  two metatar-
sal bones, as close as possible to their posterior  ends, and brought
out on the external and plantar side,  without touching any point  of
the skin;  and every thing in the way of the knife is now cut through
as far as the commissure of the  toes.   The next  step is the disar-
ticulation, which is accomplished by dividing the internal ligament,
with the point of the bistoury kept  perpendicularly, and the edge
directed rather  obliquely from  within  outwards,  and  from  behind
forwards,  so  that it may follow the direction of articular interspace.
The upper ligament having been next cut through, the edge of the
knife is turned upwards, and the point plunged between the external
side of  the first cuneiform bone  and the inner  side of the extremity
of the second metatarsal bone.   The interosseous ligament is then
divided by cutting upwards, after which the surgeon completes the
disarticulation by cutting through the few remaining ligamentous and
 muscular  fibres.
  Instead of making a second incision, after the flap is formed, the
skin may  be dissected  up, from the base of the flap as  far  as  the
joint  between the  metatarsal bone and  first  phalanx,  and drawn
outwards  by  an  assistant.  Here, as  M.  Malgaigne observes,  the
essential thing is to be able to pass the knife between the two me-
tatarsal bones, without wounding the integuments.
   Instead of disarticulation, the  first metatarsal bone is sometimes
divided with a strong pair of  cutting  pliers, which plan, if the  dis-
ease or accident will allow, has tlie advantage of being less likely
to excite  inflammation in the joints of the tarsus.*
   IV.  Amputation of other  Metatarsal Bones.—The fifth  may be
amputated in a similar way.  For the removal  of  the second, third,
or fourth, the.oval method is  often  preferred.  Biclard used to am-
putate the two first metatarsal bones as follows:—An incision is be-
gun at the first interosseous space,  six lines in  front of the articula-
tion, and  extending obliquely  as far as  the commissure between the
 second and third toes;  it next descends along  the  furrow  under the
 second and  first, and  then' passes  obliquely  upward  to the point
 where it commenced.   It is a true oval incision.   Then, from the
 upper angle of this incision, two others are made, twelve or fifteen
 lines in length;  one passing inwards and backwards, and  tbe  other
 outwards  and backwards.  The integuments  are then dissected up
 on each side, and the bone freed from the parts covering  it.  Next,
 in order to  get at  the  articulation, the posterior flap,  bounded by
 the  two last incisions, is reflected.
  * The disadvantage of removing the first metatarsal  bone, without the great toe,
has been  ably explained by Mr. Kynd.  See Dublin  Journ. of Med Science, vol,
viii. p. 292. 
            AMPUTATION  OF  PARTS OF THE FOOT.        505

  The same mode of proceeding is applicable to the disarticulation
of the fourth and fifth metatarsal bores.
  V. Amputation of the whole of the Metatarsus.—Here the joint
is formed on one hand by tbe three cuneiform bones and tbe cuboid
bone, and on the other by the  five metatarsal bones;  and its direc-
tion  is such, that its inner  side is nine  lines more forward than its
outer.   The tuberosity of the metatarsal bone of the little toe will
denote the situation  of  the joint between that bone and the cuboid;
for it is situated immediately in front of a depression, which  corres-
ponds to the articulation.  When the foot is placed  in the position
of abduction, the tendon of  the peronaeus brevis,  which is attached
to the tuberosity, may also be  seen, or felt.   The inner side of the
joint may be found by attending to the following  guides.   1. If a
transverse line be drawn from  the tuberosity of the  fifth  metatarsal
bone to  the inner edge of the foot, the joint  will be  found  three
quarters of an inch  in front of it.  2. If the forefinger be  carried
along the inner and  interior side of the first  metatarsal bone,  from
before backwards, a tuberosity is first felt, then a depression, and
lastly, a second protuberance.    The joint is between these two em-
inences.   3.  If the finger be  j assed along the inner edge of the
foot, from behind forwards,  the  prominence of the navicular  bone
is felt an inch in front of  the  malleolus  in'ernus.  The joint lies
about thirteen  or fourteen  lines still more forward.   4. If the foot
be bent  on the leg,  the tendon of the  tibialis anticus,  which  is at-
tached both to the  great cuneiform and  the first  metatarsal  bone,
may be felt.   5.  Lastly, as  Malgaigne  observes, the most prom-
inent point of  the instep, in  front of the  navicular bone, being  as-
certained, the  joint  is three lines nearer the  toes.
   As for the direction of  the  articular surface, the outer  part, be-
tween the fifth metatarsal bone and  the cuboid bone is doubly ob-
lique; at first, in the direction  of a  line,  drawn from this  point to
the  first  joint of  tbe great toe;  and then in the  direction of another
line, drawn from  the same point to the  middle of the first metatar-
sal  bone.
   The  direction of the articulation of  the fourth metatarsal bone
corresponds to a curved line,  about an inch in length, begun exter-
nally, and terminating inwardly, four lines in front of the point of
its commencement.
   The articulation  of the third metatarsal bone is nearly transverse,
and usually half  a line  more forward than the last.
   The second metatarsal  bone extends backward, being lodged in
a kind of  mortise, formed by  the three cuneiform bones, the  inter-
nal  side of which is four lines deep,  and oblique from  behind out-
wards;  while ihe external side is two lines deep, and oblique from
behind inwards.   The posterior side is six or seven lines in breadth,
and flat, and  nearly transverse.
   The articulation  of the first metatarsal bone is three lines in  ad-
   vol.  n.                   43 
506
OPERATIONS.
vance  of that  of the third, and its  direction corresponds to  a line
drawn  from  its  inner  part to the middle  of  the  fifth  metatarsal
bone.
  In respect to the ligaments, if the second  metatarsal bone be ex-
cepted, which is  fixed in the mortise by three ligaments, each meta-
tarsal bone has on its dorsal side but one ligament.  The  plantar
ligaments are not of less importance than the  three  interosseous.
The first internal one, which is  the strongest, goes  from the outer
side of the first cuneiform  bone, and the inner side of the second,
to be inserted into  the  corresponding surfaces of the first and sec-
ond metatarsal  hone.   The second, or  middle  ligament,  proceeds
from the external side of the second cuneiform  bone and ihe inner
side of the third, to the outer side of the second  metatarsal  bone,
and ihe innerjdde of ihe third.   The  third  is fixed,  on one hand,
into the outer side of the third cuneiform bor.e, and the  inner sur-
face of the cuboid;  and, on the other hand,  into the  external side
of the  third, and  the inner side of the fourth, metatarsal bone.
   In consequence of ihe foregoing arrangement, the lateral parts of
the mortise are only in immediate contact with ihe second metatar-
sal bone towards the dorsum  of the foot, and the  interspaces, left
on the plantar side  for the lodgment of  the interosseous  ligament,
will permit the point of the knife to enter.*
   L'sfranc's Method.—On the  right foot, a semilunar incision is
made across  the  instep, half an inch in front of iha joint, through
the whole thickness of tie soft  parts.   The skin  is  drawn back,
and  the point of  the knife  placed on the outer side  of the joint.
The edge, being carried in the directions above specified,  now en-
ters the joint, and passes as far as the third metatarsal bone. There
the knife is to be inclined half a line more forward, and the incision
extended almost  transversely  to the second metatarsal  bone.   In
this part of  the operation,  the  general  maxim is to be  followed of
not letting the  blade become locked in the joint, but merely to aim
at dividing the ligaments with its point.   As soon  as the  knife has
reached   the second metatarsal bone, it is  to  quit this side of the
joint, in  order  to attack it at the internal  side.   Here  it is  to  be
held perpendicularly, and introduced with tbe edge towards the tar-
sus, so as to pass close along the inner surface of the first metatar-
sal bone; and directly it is stopped  by the head of the bone back-
wards, its position is to be made  perpendicular  to the  axis of the
foot, and the joint is to be  penetrated  by a  sawing motion, in the
direction of a line extending to the  middle  of  the  fifth  metatarsal
bone.   In detaching the mortise connection, the operator passes the
point of the knife between the first cuneiform and the second meta-
tarsal bone, with the edge turned towards the leg,  and  cuts along
the whole of the inner side of the  mortise not forgetting  its slight
obliquity inwards.   In this manner, the penetration of the joint be-
* See J. F. Malgaigne, Manuel de Med. Operatoire, pp. 342—344. 
AMPUTATION
OF  PARTS  OF  THE FOOT.
507
tween tbe first and second cuneiform bone will be avoided,  and the
internal interosseous ligament  be completely  divided.   The knife
is then withdrawn, and its point carried transversely over the dorsal
ligament at the posterior part of tbe mortise,  and then from behind
forward over the dorsal ligament at its external side.   Gentle pres-
sure is now to be made on the end of the foot to  separate  the ar-
ticular surfaces;  while the external and  middle interosseous  liga-
ments  are divided  from above downwards,  with the point of the
knife.
   In finishing the operation, the surgeon places  the  foot in a per-
fectly  horizontal position, and carries the point  of the  knife freely
over the plantar ligaments;  detaches the textures which are adher-
ent to  the posterior end of the metatarsus, avoiding the  mberosities
of the  first  and fifth metatarsal  bones; and then pushing  the  knife
under  the  whole row of them,  he carries it forward along their in-
ferior  surface, and  thus forms  a semilunar flap,  the inner part of
which should be two inches long, and the outer  one  inch.  The
aim should  be to save more skin than muscle.   If any large tendons
should be left denuded in the  flap, they  are to be  cut  away with
scissors.  It is the plantar flap which is designed to cover the whole
of the wound; the small upper  flap  being only intendeds prevent
any exposure of the upper surface of the tarsal bones.   The upper
 flap should only be employed as a cover for the end  of  the foot,
 when  there is not enough  skin afforded by the state of  the limb lor
 the perfect formation of the  planter flap; because  the cicatrix will
 be situated too much  forward, and ill calculated  to bear pressure.
    VI.  Amputation at the .Middle of the Tarsus, or the Articula-
 tion between the Astragalus  and Os  calcis behind, and the navic-
 ular and cuboid Bones in front.—If the foot is extended, the outer
 side of this joint will be found twelve or fifteen lines in front of the
 extremity of the fibula;  its inner side, ten or eleven  lines in front of
 the malleolus internus ;  and its middle part, about an inch in front
 of the ankle joint.   When the  foot is flat on the ground, the ar-
 ticulation is about three quarters of an inch in  front  of the  tibia ;
 but, when  extended,  tbe interspace may be  nearly  thr.ee  this mea-
 surement.   Another  guide is the mid-point  between the malleolus
 externus and the tuberosity of the fifth metatarsal  bone ; here is the
 articulation between the os calcis and the oscuboides,  situated, ac-
 cording to Lisfranc, six lines  behind  that  tuberosity.   In passing
 the fi lger alon°- the outer side of the foot from the malleous  exter-
 nus, the first tuberosity met with is formed by the os calcis, and the
 joint  is in front of it.   To find the inner end of the joint the fin-
 cer mav be passed forward along the  internal side of the  foot from
 the malleolus internus;  and the first protuberance met with, will  be
  that of the navicular bone: the articulation is directly  behind  it.
  fBicherand )   The precise situation of the upper  and middle part
  of the joint may be ascertained by extending the foot, and placing 
508
OPERATIONS.
it-in the position  of adduction; if the finger is now put on the junc-
tion of the external with the middle third of the iniermalleolar space,
and  the instep traced with it, the first  eminence met with, will be
the head of the astragalus, constituting part of the joint itself.  (Du-
puytren.)
   As for  tbe direction of the articular  surfaces,  w hen the foot is
bent, tbe  astragalus and os calcis are nearly in the same line ; when
it is extended, the os calcis advances at least  three lines more  for-
ward than the astragalus.   The navicular bone extends a good way
towards the maleolus internus, and here the direction of the artic-
ulation is  that of a line, drawn from the back and inner part of that
bone, to the  place of junction of the posterior  with the middle third
of the fifth metatarsal bone.   In its middle third, the articulation in-
clines slightly backwards  towards the  malleolus exturnus ;" then it
turns a little forwards, and lastly rather  backwards  again.  There-
fore, in cutting into the joint at its external side, the knife should be
inclined a little forwards.
   The most  important ligament,  the  true key to the  joint, as  M.
Malgaigne expresses himself, is the interosseous, attached on one
side to the os calcis and  the  astragalus ;  and,  on the other, to  the
navicular  and cuboid bones.   Its situation  corresponds to the  de-
pression of the external  and inferior side of the head of  the astra-
galus: and here it must be attacked.
   The operation is performed  on  the  left  foot as follows :—The
surgeon places his  left thumb on the external  side of the joint, and
his fore-finger on the tuberosity of  the  navicular bone.   Between
these two  points a  semilunar incision  is made, the  middle part of
which should be half an inch in front of the joint.   Tbe inner  part
of the joint is then opened in the direction above particularised, and
the knife then carried to  the front  of the head of  the  astragalus.
The dorsal ligaments are then cut with the  part of the edge of tbe
knife near its point;  and  next the outer side of the  joint is opened
with the edge inclined a little forwards.  The point is  now intro-
duced under  the external  aud anterior side of the head of the astra-
galus, and, with the edge turned forwards, the interosseous ligament
is cut in the direction of the articular surface of the os calcis.
   The joint being thus freely laid open, the  plantar ligaments are
to be divided, and  the  knife  conveyed  close under the bones, to
form a suitable  flap.   This is  most  expeditiously  done, I think,
by transfixion.  In this part of the operation,  care  should  be taken
to avoid the  protuberances of the navicular  and  cuboid bones,  and
beyond them, those  of the first and fifth metatarsal bones.*
   The plantar and dorsal arteries of the foot  having been secured,
the flap is to be brought over tbe astragalus  and os calcis, and fixed
♦ See J. F. Malgaigne, Man. de Mtd Ope'ratoire, p. 347. 
LIGATURE OF  THE COMMON CAROTID ARTERY.     509
by means of adhesive plaster, with or without the aid of a couple of
sutures.
   I have seen cases, iri which the remainder of the foot after this
operation was so serviceable, that the patients walked with but  a
very trivial degree of lameness.  Mr. Copland Hutchison sent one of
his patients to my bouse, on  whom  the operation had proved  ihus
successful.   However, Dupuytren, Lisfranc, and  some other  emi-
nent surgeons,  prefer amputating  at the junction of  the metatarsal
bones with ihe first phalanges of the toes, whenever  the state of the
limb will allow it, because, the whole of the tarsus being preserved,
the anterior lever of the foot continues greater than  the  posterior;
and the extensor tendons of  the toes adhering to the cicatrix, aided
by that qf the tibialis amicus, inserted into the inner cuneiform and
first  metatarsal bones, prevent the foot from  being displaced back-
ward;  a  serious grievance, which,  though not constant,  is alleged
to have sometimes followed Chopart's operation, and required  a di-
vision of the tendo Achillis.   This operation is not  well  suited for
scrofulous disease of the foot; nor for mortification, which is either
spreading, or has already reached  on  any side above the place of
the incisions.
             OPERATIONS  ON ARTERIES.

        LIGATURE OF  THE  COMMON CAROTID  ARTERY.

  This operation is occasionally necessary for  the  cure of aneu-
rism; the  stoppage of hemorrhage; and the cure  of ceitain tumors,
composed of vascular  erectile tissue, growing within the orbit.   It
has also been undertaken  in cases, where  extensive tumors of this
character  were situated  on other parts of the face and head, but,  as
I believe, without any decided success.*   The operation has been
somstimes resorted to   for the prevention  of hemorrhage in the re-
moval  of the  lower jaw, and  large swellings of ihe neck.   This
practice is not, however, usually adopted by the most judicious sur-
geons, who know, that  a double  operation is  generally avoidable,
either by pressing the common carotid artery against the transverse
processes of the  cervical vertebra?, if necessary, or by lying,  or
pressing on the mouth of, every large artery, as soon as such vessel
is divided.
  The right common carotid, which arises from the  innominata op-
  * See Ve'paau, Nouvcaux, El.'m. de Mwl Oper.  t. i. p. 539, where many trials of
this practice are rjfjrred to.  The result is very discouraging.
                          43* 
510
OPERATIONS.
posite the sterno-clavicular articulation, is shorter, and, at its com-
mencement, more superficial, than the  left, which originates further
back from the arch  of the aorta.   Alter emerging from the chest,
each of them has at its inner side the trachea,  and  higher up tbe
thyroid  gland (which sometimes overlaps it), the pharynx, and  the
larynx, near which it continues  up to its usual  place of bifurcation,
the upper edge of the thyroid cartilage.  At its external side is the
internal jugular vein, which partly overlaps it;  while  between the
two vessels, and rather behind  them, the pneumogastric nerve de-
scends enclosed with them in the  same sheath of condensed cellular
tissue.   Behind the sheath is situated the great sympathetic nerve,
resting on the rectus amicus muscle; while the inferior thyroid arte-
ry also crosses from behind  the lower portion of the same sheath in
its  course inwards and  upwards towards the  thyroid  gland.   The
nervus descendens  noni usually lies on the forepart of the sheath;
though occasionally some of the twigs,  derived from the arch form-
ed by its junction with two filaments of the cervical plexus, are found
within the sheath  lower down the neck.  The common carotid ar-
tery may be regarded as resting on the  transverse processes of the
cervical vertebrae, with the interposition of the longus  colli and rec-
tus capitis amicus muscles.  On its outer side, and near its root, it
is covered  by the  sterno-mastoid muscle, which gradually passes
backward, so as no longer to  conceal it.  On its  inner side, it is
covered, first by the outer border of the stemo-hyoid and sterno-
thyroid muscles, and then by the  corresponding lobe of the thyroid
gland, and several considerable veins of the face  and neck, as they
are proceeding towards the internal jugular vein.   It is divided into
two  portions  by the omohyoideus  muscle which crosses over the
anterior surface of the sheath, about the middle of the neck, or op-
posite the upper  rings  of the  trachea.  In fact, as Velpeau ob-
serves, this little muscle, as it ascends from behind  tbe stemo-mas-
toideus to the os hyoides, divides the side  of the neck into two
very regular triangular  spaces.   In the lower one,  the sides  of
which are formed by the trachea, the clavicle, and the omohyoideus,
the artery is concealed  by the  inner border of the sterno-mastoid
muscle, and is deeply situated;  while in the upper triangular space,
bounded externally  by  the  margin of the  sterno-mastoid muscle,
above by a transverse line  drawn across from  the os  hyoides, and
below by the omohyoideus, the  situation of the  artery is more
superficial.
   1. Operation below the  Omohyoideus.—The patient  should lie
on his back, with the neck extended, and the head turned towards
the opposite side.   The anterior  edge  of the sterno-mastoid mus-
cle is the guide for the external  incision, which should  be  about
three inches in  length,  terminating a little wav  above  the  sternum.
The first stroke of the knife divides the skin,  superficial fascia, and
platysma myoides.  Thus the edge of the sterno-mastoid muscle is 
        LIGATURE OF  THE COMMON CAROTID  ARTERY.     511

exposed.   This is to be drawn to the outer side otthe wound, and
the sterno-thyroid and  sterno-hyoid  muscles towards  the trachea,
when the deep cervical fascia will  be  brought into view, and require
to be carefully divided: for this  purpose, a  portion of it  may be
pinched up wish the forceps, and  cut with the edge  of the  knife
kept horizontally, and  close to the end of the forceps.  Into the
opening thus made, a director is to be introduced, along  which the
further division of the fascia may be safely made.   The sheath is to
be carefully opened in the  same manner, and  so as to avoid the in-
ternal jugular vein and nervus descendens noni, but only to the ex-
tent of half an inch, in order not  to  disturb the connections of the
artery more  than absolutely requisite for the  passage of the aneu-
rism needle and  ligature under it,  according to the principles  advo-
cated in the consideration of the subject of hemorrhage.
   Were it necessary to tie the common carotid very low down, an
jncision mij;ht be made three inches in length, beginning at the ster-
nal end of the clavicle, and  carried obliquely upwards and outwards,
over the interspace  between the sternal and clavicular  portions of
the sterno mastoid muscle.   The skin, platysma myoides, cellular
tissue, and fasca are then to be  cautiously divided  in  succession,
while the two portions of the muscles are held apart.   The jugular
vein will now present itself, at the inner side of which will be found
the artery, in  front of the longus colli, the vertebral artery and vein,
and the great sympathetic nerve, which last is in close relation to the
posterior part of the sheath.  After the sheath has been opened, the
surgeon should separate the artery, from the vein and nervus vagus,
and apply the ligature according  to the following rule, which is ap-
plicable to the ligature of great arteries in general:—The aneurism
needle, eye probe, or whatever  other instrument  is employed for
theccnveyance of the ligature under the artery, is to be passed between
the artery and vein, with the point turned away from the latter ves-
sel, and guided closely round the  artery, by which means the vein,
together with the nervus vagus,  in this instance, will  not be endan-
gered by the needle, and, at the same time, will be safely excluded,
from  the  ligature.   The  point of an  aneurism  needle, however,
should never be so sharp as to be  likely to wound  either the  artery
or  vein, yet  fine enough to pierce with facility the  cellular  tissue
connecting the in'.erior of the sheath  to the artery.
   2.  Operation  aSove the   Omohyoideus.—From the point where
the common  carotid is crossed by the omohyoideus, opposite the
upper rings of tbe trachea, up to its bifurcation, the artery is cover-
ed only by the integuments, platysma myoides, and  fascia, for the
sterno-mastoid muscle has now diverged  from it  backwards in its
course towards the mastoid process.  However, though this part
of the carotid artery is  thus superficial, it is frequently covered by
a plexus of  veins.
   The chin  being turned  towards the  opposite side, the  first inci- 
512
OPERATIONS.
sion is to  commence on a level with the os hyoides, and to extend
downwards,  about two inches and a  half, near the inner border of
the sterno-mastoid  muscle.  The skin,  platysma hyoides, and fas-
cia having been divided, and the sterno-mastoid  muscle drawn a lit-
tle towards the outer side of the neck, the sheath  of the great ves-
sels,  with the  nervus descendens noni in front of, or to the outer
side of it,  is seen immediately above the omohyoideus muscle.  The
surgeon, avoiding the nerve, now opens the sheath,  and passes  the
aneurism  needle with the ligature  between the internal jugular vein
and  the carotid artery, from without inwards, and closely under  the
latter vessel, for reasons already explained.                     ^
   By extending the incision upwards towards the  mastoid  process,
the external carotid  might be exposed as high up as the point where
it reaches the tendon of the digastricus muscle, and a ligature appli-
ed half an inch above the bifurcation;  but for various considerations,
one  of  which is the nearness of the ligature to  a collateral branch,
and  the danger of this interfering with the  closure of  the vessel, it
is  generally deemed more advantageous  to take up the common  ca-
rotid.   Even in a wound, it might sometimes be difficult  to ascer-
tain  positively, whether the bleeding proceeded  from the latter ves-
sel,  or the external or  internal carotid.*

 LIGATURE  OF THE ARTERIA  INNOMINATA,  OR  BRACHIOCE-
                        PHALIC TRUNK.

   This, which is the first branch given oft" by the arch of the aorta,
arises at the junction of the ascending  with the transverse  part of
that arch; and is situated behind the first bone of the sternum; pass-
ing obliquely upwards to behind the right  sterno-clavicular articula-
tion, where it divides into the  right subclavian and right carotid ar-
teries.   Above, it is separated from  the first bone of the  sternum
by the sterno-hyoid and sterno-thyroid muscles; and below, by the
left  subclavian vein, which crosses it.f   Its external side is in con-
tact with  the pleura, while its inner rests  upon.the trachea.  It va-
ries in length from one to two inches, and is sometimes wanting; in
which case,  the right carotid and subclavian arteries arise from the
arch of the aorta separately.   The pneumo-gastric nerve and inter-
nal jugular vein lie a good way external to it.  Between the sternd-
thyroid and  sterno-hyoid muscles and the arteria innominata, a very
loose cellular tissue  intervenes,  in which lie several veins descend-
ing  from  the thyroid gland to the left subclavian vein.
   In the method of operating commonly advised, the skin, the su-
perficial  fascia, the platysma  myoides, the sterno-mastoid,  sterno-
  * See P. J. Manec, Traite Tht'orique et  Pratique de la Ligatures des Artfres, fol.
Paris, 1832  Also Alf. Velpeau, Nouveaux I'.Kin. de M<d. Operatoire, t. i. p. 244.
  t See Dr. Quuin's Elements of Anatomy, p. 432. ed. 2d. 
LIGATURE OF  THE  ARTERIA  INNOMINATA.       513
hyoid, and sterno-thyroid muscle?, are tbe principal parts cut;  but
no vessel, nor  nerve of importance, is injured.   Yet if, instead  of
searching for the innominata from before backwards, and rather from
above downwards, calculating from the sterno-clavicular articulation,
the surgeon were to cut  too  far outwards, the pneumo-gastric and
recurrent nerves, and  the internal jugular vein, and  principal  bran-
ches of the subclavian artery, would be endangered.
   First Method.—The patient is  to be placed on his back, with his
head considerably extended backward, so as to bring the innominata
as high up as  possible.   The first incision  is to  begin  immediately
above the sternum,  at the mid-point  between tbe two sterno-mas-
toid muscles, and extend over the origins of the  right  sterno-mas-
toid muscle, three inches towards the right shoulder, at  the distance
of about half an inch above the clavicle.    By this the  skin, super-
ficial fascia, and platysma myoides, are divided.  Another incision,
about two inches in length, is  then made at  the inner border of the
right sterno-mastoid muscle, so  as to join the inner end of the first.
The next thing is to cut through the  sternal origin  and part of the
clavicular attachment of the sterno-mastoid  muscle, which may  be
safely done with the aid of a  director.  The flap is tl:en  reflected
outwards.   The operator has now brought  into view the  deep cer-
vical  fascia, and the outer portions of  the sterno-hyoid and sterno-
thyroid muscles, under which a  director is to be passed, when they
may be cut through  with  a probe-pointed  bistoury.   After this, a
cutting  instrument is not to be employed,  but the artery  separated
from its connections with  tbe  aid of a  director,  or other blunt in-
strument; and, in detaching  the vessel at  its  outer and  posterior
part, great care must be  taken  not to lacerate  the pleura.   The
aneurism needle  is  then  to  be  conveyed  between the artery, the
pneuinogastric  nerve,  and  the  pleura on  one side, and its point
brought out between the artery and the  trachea on the other.   Manec
considers the perpendicular incision superfluous,  but Dr. Molt and
Professor  Graefe,  who have had occasion to tie the innominata in
the living subject, both made  the incision at the inner side of the
sterno-mastoid muscle.  With regard  to the fate  of the patients,
one died on the 26th day  after the operation; the other on the 56tb.
A case under Mr. Lizars had a similar end.
   Second Method.—An incision, between  two and three inches in
length, is first made near  the  lower part of  the  internal margin  of
the sterno-mastoid muscle, and  parallel to it.  With the fingers, cr
a director, the operator then separates the cellular tissue interposed
between the sterno-mastoid and  the sterno-hyoid and sterno-thyroid
muscles, and  then  also separates  that which intervenes between
these two muscles and the trachea.    On reaching the cellu'ar tis-
sue, in which the  veins from the thyroid  gland  ramify, they are
pushed aside, or cut through, after having been tied.   The patient's
head being now bent forward, the surgeon passes his forefinger be- 
514
OPERATIONS.
tween the trachea and  the sterno-hyoid muscle, and feels the artery:
with a blunt curve 1 probe,  it is separated from its connection, first
on the right side, then  on the left, and lastly below.   The Igature
is then applied, as already explained.   This  plan,  which  was sug-
gested by the late  Mr. King,  has never been  tried  on the  living
subject.

 LIGATURE  OF THE  SUBCLAVIAN ARTERY,  WHERE  IT  PASSES
                     OVER  THE FIRST  RIB.

   The subclavian artery ought to be studied, first in the part, of its
course before it reaches the scalenus*; secondly, where it is passing
behind that muscle; and thirdly, from the outer border of the same
muscle to  the  outer   edge  of  the first rib.f   In the  first division
of their course, the right and letfsubclavian arteries differ considerably.
The right is larger and shorter than the left, which, as coming from
the arch of the aorta, is more  deeply placed.   But, after reaching
the internal edge of the scalenus amicus muscle,  both  arteries have
nearly the same relations to other organs.  In  the  latter, or  third,
division of  its course, the  artery  lies deeply within  a  triangular
space, bounded upwards  and outwards  by  the omohyoideus; in-
wards by the scalenus  amicus; and  below  by the clavicle.   After
passing from  behind the scalenus,  its direction is outwards and
downwards  over the pleura and a groove  in the first rib.   The left,
however, lies more closely to the rib; the right being only in con-
tact with  its outer  edge.J   The artery  is  necessarily beneath  the
clavicle and  behind  the subclavius muscle.   Above, it is in contact
with the dorsal nerve of the brachial plexus; while, in the direction
forwards, and  a little  below  the artery,  is placed the subclavian
vein, which reaches this situation  by passing in  front of the  scale-
nus amicus, while tbe artery passes behind  it.   At this point, then,
the scalenus"amicus is  interposed between the artery  and  the vein,
with  the  phrenic nerve descending near  the inner  border  of it.
The cervical nerves, converging to form  the  brachial  plexus,  pass
above and  more  backward  than the subclavian artery, in front
of the scalenus posticus, and consequently they and the artery must
lie  in the space  between  this muscle  and  the scalenus amicus.
In the triangular space, already described,  the artery may be  got
at by dividing the following parts:—1st, the skin; 2d, the superficial
fascia;   3J, the platysma myoides; 4th, the  deep cervical  fascia;
5th, a quantity of cellular  tissue,  which is  interspersed  not only
  * The right suhel ivi-in artery has been taken up in this pla-,c by Mr. Liston in two
instances of subclavian aneurism, in University College Hospital.  In one of the cases,
the right carotid artery was also tied at it* origin.  In both examples, fatal hemorrhage
ensued from ihe artery on tht> distal side ol the ligature.
  t See Dupuytren, Lemons O.ales de Clinirjue Chir. t. iv. p. 523.
  X See P. J. Manec, De la Ligature des ArU'res. 
           LIGATURE  OF  THE SUBCLAVIAN ARTERY.        515

with veins, and  lymphatic glands, but pervaded by two arteries of
importance, namely, first, the  supra-scapular, which runs under the
back  edge of the clavicle towards  the  loot of the  coiacoid pro-
cess,  and,  secondly, the posterior scapular artery, which, after hav-
ing arrived at the posterior angle of the scapula/descends  along  its
base to its  inferior angle.   It is between these two arteries, ihen,
that the surgeon  has to make his way to  the subclavian.  When the
attachment of the sterno-mastoid  muscle to the  clavicle  is exten-
sive,  it is necessary to divide also a part of it.   Within the above
triangular space,  ihe external j gular vein, as well as several of its
branches,  descends; and  if it lie rather more towards the cuter
side of the neck  than  ordinary, and  cannot  be pushed  si fficiently
inwards, it may be indispensable to divide it after a double Igature
has been introduced  under it.   In  individuals  whose necks  are
short, the first rib is shuaied very low,  in relation to the clavicle,
and consequently the depth of the subclavian artery is considerable.
The same  disadvantage may be produced by the aneurismal tumor
pushing the clavicle upwards.  In general, when  the  neck is long,
the interspace between the clavicle and  first  rib  is but moderate,
and the subclavian  artery is  consequently  less  distant  from  the
skin.f  But one  of ihe most essential  points of  surgical anatomy,
with reference to the  ligature of ihe third division of the  subclavi-
an artery, is the  tubercle  of the fiist rib, to  which the scalenus an-
ticus  is attached, and  close to  the outer side of which the artery
always passes.
   Operation.—1. If the  state of the disease will allow, the shoulder
is to  be depressed and  pushed  forwards.   The situation of the
external jugular vein having been ascertained in order that  it may
not be cut, if possible,  an incision is made directly above the clavicle,
and parallel to its posterior border, beginning cue inch  from the ster-
nal end of  that bone, and terminating at  ihe  insertion  of the  trape-
zit s;  or, I may say, that it  should extend nearly to the anterior margin
of tli3 trapezius, about two thirds of the way along the posterior border
of the clavicle.   If the operator conceitves that a freer division of the
integumenis will  facilitate  the operation, he may  make a perpendicu-
lar cut an inch and a half long, which is to descend along the outer
margin of ihe clavicular portion of the sterno-mastoid, and join the
liorzoutal incision.  2. The skin, superficiid fascia, and  platysma
myoides, baying  been  divided, and the external jugular vein  held to
one side with a blunt hook,, the surgeon  may next divide a  part of
llie sterno-mastoid muscle, if its  extension outwards  should  render
this proceeding advisable.   3.  The omohyoideus, situated between
the two layers of the cervical  fascia, mny now  be seen crossing the
outer extremity of the wound, and tbe deep cervical  fascia is found
to  stop the  surgeon's advance  more  deeply towards the  artery;
consequently it is to be cautiously divided with  the aid  of a direc-
t See Dupuytren, Lemons Oiales de Ciinique Chir. t. iv. p. 578. 
516
OPERATIONS.
tor, after  which no  further use of a cutting  instrument should  be
made.   4. With a probe, or  director, the surgeon  now separates
the cellular tissue, and searches for the external  border of  the sca-
lenus anticus at the anterior and  inner  part of the wound,—a sure
guide to the artery;  for, by tracing it downwards with the left fore-
finger,  he  is conducted to the tubercle of the first  rib, immediately
external to which, the artery will be felt  pulsating.   5.  Under  the
guidance  of the same finger, the  ligature  is then cautiously intro-
duced under the artery, by means of a common aneurism needle;
or, if necessary, that invented by Weiss, or others expressly made
to convey ligatures under arteries inconveniently placed  for the use
of common  means.    The  point of the needle,  which  should
never be too sharp, is to be passed under the artery, directed from
before  backwards, in order not to endanger the  subclavian vein;
and just at the moment when the needle is passing, the operator is
to keep the  artery down with his  left fore-finger, so that the point
of the  needle may have room to be brought up, without getting hold
of the  lowermost nerve of the brachial plexus.
   M. Blandin refers to an instance, in which the subclavian vein
passed  behind  the scalenus anticus, between  the muscle and  the
artery  (Anatomie  Topographique); and  M.  Manec saw an exam-
ple, in which the subclavian artery was in front  of the scalenus an-
ticus, between that muscle and the vein.   The possibility of such
anomalies should be  remembered.

LIGATURE OF  THE SUBCLAVIAN ARTERY IN  THE  SECOND DIVI-
     SION  OF  ITS  COURSE,  OR  BETWEEN THE SCALENI.

   The operation is begun in the manner of the preceding one;  and
the tubercle of the first rib having been  felt, a  director, somewhat
bent, is introduced behind the interior scalenus, and  the lower  at-
tachment  of this muscle divided with a probe-pointed bistoury.   In
this part of the operation,  care must be taken not  to  injure the
phrenic nerve,  which descends along the inner margin of the scale-
nus anticus, and a little in front of it; nor the subclavian vein.  The
muscle, directly it is cut, is retracted, leaving the artery exposed,
under which the director may  then be passed  in  Dupuytren's way
from without inwards, along the groove of which an eye-probe with
the ligature  is to follow.   Thus,  he  avoided including the nearest
nerve of the brachial plexus,  and  though the director  and eye-
probe were  passed from without  inwards,  the  subclavian vein  was
perfectly safe, because no instrument capable of puncturing it was
employed. 
LIGATURE OF THE
BRACHIAL ARTERY.
517
LIGATURE  OF   THE   BRACHIAL  ARTERY  IN THE MIDDLE AND
                  UPPER  PARTS OF  THE ARM.

   The brachial artery commences at the lower margin of the axil-
la, and terminates about three quarters of an  inch  below the bend
of the elbow, its  course corresponding  to a  line drawn  from the
centre of the armpit to tbe middle point  between the  condyles  of
the humerus.   In the  upper half of the  arm, it lies near the inner
margin of the coraco-brachialis, and then crossing over the insertion
of tbis muscle, it becomes situated at the inner side of the biceps,
which partly overlaps  it, especially when the fore-arm is in the prone
position.   At first,  the artery lies in  front of the  triceps muscle,
but  below  the  insertion of the coraco-brachialis: the muscle,  on
which it rests during the rest  of its course, is  the brachialis anticus.
The median nerve,  which, above, runs along its acromial margin,
soon gets in front of it, and,  crossing  it  about the  middle  of the
arm, lies completely upon its inner side below.  Two satellite veins
accompany the artery, and sometimes even cover it, or separate it
from the median nerve.   The ulnar and  internal cutaneous nerves,
which run near the artery above, separate further and further from it,
as they descend.   In  thin  subjects, the artery is but a  very little
way under the fascia,  which sends off a duplicature, for the  invest-
ment of the artery,  the accompanying veins, and the median nerve.
In the lower third of the arm, the trunk of the basilic  vein lies over
the track of the artery.   Amongst the anomalies deserving notice,
is the high bifurcation  of the  artery, a  frequent  occurrence*; and
the occasional passage of the  median nerve  under the  arteryf, a
rarer circumstance.   In all ordinary  cases,  this  nerve is  the  first
cord met with behind  the inner edge of the biceps, below the inser-
tion of the  coraco-brachialis.
   In selecting the place for the external incision, four circumstances
serve as our guide.   1.   In the upper  part of the arm, the inner
border of the coraco-brachialis, which, in a  muscular person, rather
overlaps the vessel, but below the  insertion of this muscle, namely,
all along the lower half of the arm, the inner edge of the  biceps de-
notes the best place for the external incision.   2. The oblique line
drawn from the middle of  the armpit to the middle  of the space be-
tween  the condyles  of the humerus.   3. Placing the fingers of the
left hand on the track  of the median nerve, and making the incision
just at its inner side, as directed by  Lisfranc  with  reference to the
lower  half of the  arm.  4. The pulsation of  the artery.
  * In n case of circumscribed false aneurism, Dr. Browne, of St. Mark's Hospital,
tied both branches with success, the omission of which practice has in some other in-
stances been followed by the d"ath of the patients from hemorrhage.   See  Dublia
Journ. of Med. Science, vol. viii. p. 253.
  t See Velpeau, Nouveaux Elem. de M^d. Op. t. i. p. 212.
   vol.  n.                 44 
518
OPERATIONS.
  An incision, three  inches in length,  having been made through
the  integuments, the surgeon passes his left forefinger  into the
wound, and ascertains again the precise  situation of the artery and
median nerve.   With the aid  of a director, the fascia is next divid-
ed to the extent of  the external incision.   The median nerve is the
first cord now met with at the inner margin  of the biceps, and is
easily known by its firm round feel and white color: it is to be sep-
arated  with a probe or director from the  sheath, and the artery will
be found either directly under it, or, if the operation  be done low
down the limb, at its  external side.   Further  inwards,  lies the in-
ternal cutaneous nerve;  and five or six lines backward,  is the ulnar.
The sheath having been opened, the ligature is to be passed under
the artery, with the precaution of not including the veins.
  In order not to mistake the ulnar for  the  median nerve, which
would  cause much confusion,  it is  advantageous to direct the inci-
sions from the front towards the back of the limb.
  In the  upper  part of  the  arm,  the  external  incision is to cor-
respond to the inner margin of the coraco-brachialis; and,  very
high up, the median nerve will present itself on the acromial side of
the artery.

LIGATURE  OF THE  BRACHIAL ARTERY  AT  THE  BEND  OF  THE
                             ELBOW.

   An  incision is to be made, two inches and a half or three inches
long, parallel  to the radial edge of the pronator  radii teres, begin-
ning nearly an inch above the trochlea, and ending at the  central
point between the condyles of the  humerus.   Under the skin are
situated the median and basilic veins, with the accompanying bran-
ches of the internal cutaneous nerve.   An assistant holds these ves-
sels aside with a blunt hook, or the end  of a bent probe.  The fas-
cia is now arrived at, which should be divided on a director, as well
as the aponeurosis  coming off* from the  biceps.   Then, having de-
tached the artery from the adjacent cellular tissue and fat, and from
the deep veins, as well as the median  nerve, the  surgeon should
pass an eye-probe between the  artery  and the latter nerve.   The
artery will be found resting upon the inner portion of the brachialis
 anticus, between the  biceps and the pronator radii teres.  Pursuing
 its course downwards  and forwards, and from within outwards, it
 crosses completely over  the tendon of the biceps  low down.  A
 deep-seated vein runs near its radial margin; and the median nerve,
 which sometimes touches its ulnar  edge, is often  separated from it
 by a few fibres of  the brachialis.*
* See Velpeau, Nouveaux Elem. de Med, Operatoire, t. i. 
LIGATURE OF  THE EXTERNAL  ILIAC ARTERY.     519
         LIGATURE OF  THE EXTERNAL ILIAC  ARTERY.

  The aorta, having reached the body of the fourth  lumbar verte-
bra, bifurcates into the two common  iliac  arteries, which diverge
from one another as they pass to the sacro-iliac symphysis.  Here
each of these trunks subdivides  into the internal and  external iliac
arteries.   From the sacro-iliac symphysis, where the external iliac
artery begins, down to Poupart's ligament,  where it  terminates,  it
describes a gentle curve  with the convexity outwards, which curve
is greater in women than men, and always more marked the broad-
er the pelvis is.   The course of the artery is obliquely downwards
and outwards, to the  middle point between the anterior superior
spinous process  of the ilium, and the symphysis pubis.   In its de-
scent, it lies upon the inner border of the  psoas muscle, with the
external iliac vein at first behind it, and afterwards on its inner side,
connected to it by a loose cellular tissue,  that is readily torn.   The
anterior crural nerve is separated from the external iliac artery  by
the psoas muscle.  The artery  is connected behind to the iliac fas-
cia by a cellular  tissue, which adheres firmly to each side of the ves-
sel.   In front of this fascia is the peritoneum, loosely connected to
it.   The  internal branch of  the genito-crural nerve,  in its descent
from the lumbar plexus to the upper and internal part of the  thigh,
runs along the inner and  front surface of the artery.   Several lym-
phatic glands are contiguous to the artery, as it passes down to Pou-
part's ligament.   The ureter crosses  over the lower  part  of the
common iliac artery, and the spermatic vessels cross  in front of the
external iliac artery.  No branches are given off from the latter ar-
tery until it has nearly reached Poupart's  ligament, where the cir-
cumflexa ilii arises from  its outer, and the epigrastric  from its inner
side.   The intestines, lying between the artery and the  parietes of
the abdomen, may readily be lifted  up from  that vessel,  together
with the peritoneum.   For the purpose of applying a ligature to the
external iliac artery, the following parts must be divided:—1. The
integuments.  2.  The superficial fascia.   3.  The aponeurosis  of
the external oblique muscle.  4. The internal oblique muscle.   5.
The transverse muscle.   6.  The fascia transversalis.  But the pe-
ritoneum, which can be raised from the iliac fossa, should not be
wounded.   Care  must also be taken not  to injure the external iliac
vein, and  the epigastric  artery, which  ascends obliquely  upwards
and inwards, between the  fascia transversalis and the peritoneum,
at the inner side  of the  internal abdominal ring.   In consequence
of the situation of the origin of the internal iliac  artery, a ligature
cannot be applied more than three inches above Poupart's ligament,
without great risk of  failure.
   Operation.—Abernethy''s Method.—The incision is made through
the integuments, beginning above  Poupart's ligament, half an inch 
520
OPERATIONS.
on the outside of the abdominal ring,  and extending  obliquely up-
wards about three inches in the  course of the  artery.   The  skin,
superficial  fascia, and  aponeurosis of  the  external oblique muscle
having been divided, the left forefinger is  introduced, at the lower
angle of the incision, under the lower border of tbe internal oblique
and transverse muscles, which are also to be divided with a probe-
pointed bistoury  to the extent of  an inch and. a  half.   The fascia
transversalis having been cautiously opened with the aid of a direc-
tor, the peritoneum and  bowels are to be pushed upwards and in-
wards over the psoas muscle, so as to expose the external  iliac ar-
tery, an inch and a half, or two inches, above  Poupart's ligament.
With a common aneurism needle, or that of Weiss,  a ligature  is
then passed under the artery  from  within outwards, by which means
the vein will not be  endangered.
   Sir Astley Cooper's Method.—A semilunar incision, three inches
long, is made through the integuments, in the direction of the fibres
of the aponeurosis of the  external oblique muscle, with its convex-
ity downwards  and outwards.  It commences a  little way in front
of the anterior superior spinous process of the ilium, and terminates
near the abdominal ring.   The  aponeurosis of the external oblique
muscle is next divided in the same direction.   On raising the semi-
lunar flap, the spermatic vessels are seen and these serve as a guide
to the opening in the fascia transversalis, named the internal abdom-
inal ring, a little to the inner side of which the epigastric artery runs.
The finger being now passed below the cord,  the external iliac ar-
tery will be felt pulsating directly  behind the internal ring, where  it
may be easily taken up.   The latter opening is placed nearly at the
mid point of the  crural arch.  It is to be divided in the direction
outwards with a probe-pointed bistoury, guided  along a director.
   Mr. Norman cuts in the direction of Poupart's ligament; but, in
other respects, follows Sir Astley Cooper's plan.   M. Roux begins
the incision a little above, and half an  inch from the spine of the il-
ium, and lets it terminate  at the centre of the crural arch.
   Velpeau'$ Method.—A slightly curved incision, three inches long,
is made parallel to Poupart's ligament, but a little above it, the cen-
tre of which is to correspond to  the  place of the artery.   By the
first stroke of the knife, the  skin and superficial fascia  are divided.
 Then the aponeurosis of the external  oblique, which is cut on a di-
rector.  Next tbe fibres of the internal oblique present themselves,
the lower portion of which are  detached with  the end of a probe,
 or director, and pushed with it upwards and backwards, while the
 lower margin of  the wound is pressed  downwards with the forefin-
 ger of the left hand.  The fascia transversalis is torn in tbe same
 way as far as the spermatic cord, which is to be  pushed in tbe same
 direction as the fibres of the internal oblique.
    The cellular tissue,  connecting the artery to  the iliac  fascia, is
 now ruptured with a probe or director, which  instrument is toeo to 
          LIGATURE  OF THE  COMMON  ILIAC ARTERY.       521

be conveyed  to the inner side of the  artery,  and moved  gently
backwards and forwards, in order to separate the artery from  the
vein.  The ligature is next conveyed under the artery with an eye-
probe, or an aneurism needle*  Care is  taken to tie the artery suf-
ficiently above the epigastric.   Beclard  lost  his patient  by placing
the ligature below it; and hence, Bogros always  looks for the epi-
gastric, before he searches for the external iliac.
  During the other steps of the operation, the abdominal muscles
should be relaxed, and the  patient make no efforts, for otherwise
the bowels will force themselves against  the wound, and the perito-
neum be exposed to injury.  Whatever  method  be preferred,  the
course of the epigastric artery  at the inner side of the internal ring,
between the peritoneum and the fascia  transversalis,  must be  re-
membered.  In one instance it was wounded by Dupuytren.

          LIGATURE  OF THE  COMMON ILIAC  ARTERY.

   The bifurcation of the aorta generally takes place on the fifth lum-
bar vertebra, but sometimes on the fourth, which circumstance must
make a difference in the length of that artery, in different subjects.
The right common iliac artery is longer than  the left, because  the
bifurcation of the aorta is situated rather to the  left of the median
line.   The right common iliac artery descends obliquely over the
last lumbar vertebra, from which it is separated by the common ili-
ac veins in their  passage to the vena cava.  Its own corresponding
vein is first behind it, and then internal to it; while, on the left side,
the common iliac vein runs along the inner side of the artery, having
first  passed under the right common iliac artery.   The common ili-
ac artery  lies  behind the peritoneum, and is crossed by  the ureter
just  before it reaches the sacro-iliac symphysis,  where  it divides.
The left has the  sigmoid flexure of the colon in front of it; and the
right, a portion of the ilium.
   In Dr. Mott's plan, an incision is begun on  the outside of  the
abdominal ring,  half an inch above Poupart's ligament, and extend-
ed, about  eight inches, to a point above the anterior  superior spi-
nous process of the ilium, in a semicircular form.
   Mr. Crampton's incision, the concavity of which was towards the
navel,  was seven inches long,  and reached  from the last rib to  the
anterior superior spinous  process of the illium.   The layers of  the
abdominal muscles, and the fascia transversalis, having been divided,
the peritoneum  and the bowels arc then pushed  forwards and  in-
wards which will also lift the ureter off the lower portion of the ar-
tery.   While an assistant holds the peritoneum  and the bowels  out
of the way,  the surgeon passes the  ligature under the artery, with
due regard to the situation of the vein.
      °                   A Ait 
522
OPERATIONS.
LIGATURE OF THE INTERNAL ILIAC  ARTERY.--MR. STEVENSr5
                           METHOD.
                                  •
   An  incision, five  inches  in  length, is  made  six  lines from the
outer side of the epigastric artery, and parallel to the course of this
vessel.   The skin, muscles, and  fascia transversalis, having  been
successively divided, the  peritoneum  is separated with the fingers,
from the  psoas and iliac muscles, and pushed inward  as far as the
bifurcation of the common iliac artery.   The pulsations of the inter-
nal iliac may then be felt in the deep part of the  wound.

            LIGATURE OF  THE  FEMORAL ARTERY.

   The femoral artery extends  downwards along  the  anterior and
inner part of the thigh, from the lower termination of the external
iliac artery and the body  of the os pubis, down to the upper part
of the  popliteal space; or we may say,  that it begins at  the crural
arch, and terminates at the junction of the middle with  the lower
third of the thigh,  where it passes through an opening in the adduc-
tor magnus, and then becomes the popliteal artery.  Tbe direction
of its course corresponds to that of a line, drawn from the middle of
Poupart's ligament, obliquely inwards round the thigh, to the popli-
teal space.  But, as Dr. Quain has remarked, if the knee be semi-
flexed, and the limb rotated outwards, the course of the vessel may
be marked out by  a line, drawn from  midway between the anterior
superior spine of the ilium, and the symphysis pubis,  to the lower
border of the  patella.  The femoral vein accompanies the artery
through its whole course, being placed at first  on its inner side, and
on the same level with  it, but getting behind, or under it, still a little
inwards, about two inches below the os  pubis, and maintaining this
position to the end.  The artery, as it descends, becomes gradual-
ly deeper.  At first, it lies on the inner border of the psoas muscle,
by which  it is separated from the  os pubis, the brim of the acetabu-
lum, and the  hip-joint.   Lower  down,  it gets on  the pectineus
and  adductor  brevis; next on  the adductor  longus; and lastly on
the united tendons of the  latter and the adductor magnus.   Exter-
nally, the psoas muscle is interposed between  its upper portion and
the anterior crural  nerve, which, in the groin, is situated about  three
quarters of an  inch  to the outside of the artery.   The sartorius
crosses the  artery very obliquely, being, above, completely to the
outside of it:  in tbe middle part of the thigh, covering the  artery;
and below, lying on its inner side.  Two or three branches of the
anterior crural nerve run for some way along the sheath of the artery;
and the largest of  them, the nervus  saphamus, having  entered the
sheath, descends along the upper and outer side of the artery in the
middle part of its course.   In tbe upper third of the thigh, the femoral 
         OPERATION IN  THE  MIDDLE  OF THE THIGH.      523

artery is covered only by tbe integuments, the superficial fascia, the
inguinal glands, and the fascia lata.  In the middle third, it is addi-
tionally covered by the  sartorius, directly under  which is a  fascia
extended from the adductor  muscles to the vastus internus, thin
above,  but dense lower down, and constituting another  texture ly-
ing over  the  artery.  In  the  Museum  of University College is  a
fine specimen of a double  femoral  artery, the two divisions  after-
wards conjoining again  into one trunk.  Examples of a double fe-
moral vein are also on record.*

      OPERATION  IN THE  UPPER THIRD  OF THE  THIGH.

   This part of the limb  is preferred by Scarpa and many other ex-
cellent  surgeons, on  account  of the  artery being  more superficial
than in  the middle  third  of the thigh.   An incision, three inches in
length,  is made through the integuments and superficial fascia, in the
track of the artery,  as  above specified,^and  the  determination of
which in  the living body is rendered  easy by the pulsations of the
vessel,  except  in fat subjects.   The  centre  of this cut should  be
nearly four inches  below Poupart's ligament, unless  circumstances
were to compel the surgeon to take up the artery immediately below
the crural arch—between the  profunda  and  the epigastric arteries.
 The knife is to be carried down in the  track of the vessel, but  rather
to  the outer than  the inner side of it, in order  to  avoid  the vena
saphena  major, which  enters the femoral vein in this part of the
thigh.   The fascia lata having been exposed, the surgeon previous-
ly  to dividing it, is to remember, that, in the  direction downwards,
the inner edge of the sartorius separates it from the artery,  which is
not the case in the upper part  of the inguinal  triangle.   The  fascia
having  been opened nearly  to the same extent as the integuments, a
portion of the  femoral  sheath is to be lifted up with  a  pair of for-
ceps, and divided, but  only so far as to make room for the  ready
passage of an  eye-probe, or  aneurism needle, round  the artery, in
which step of  the  operation the instrument should be introduced  on
the pubic side of the artery, between this  vessel and the vein, and with
the point turned away from the latter, and brought  up again at the
external side of the  artery.  The branches  of  the anterior  crural
nerve should  not  be included in  the ligature, one  half of which,
after a  knot has been made,  is to be cut  off, so  as to  lessen the
quantity of extraneous matter in the wound.    The edges of the  in-
cision are then to be brought together.

          OPERATION IN THE  MIDDLE  OF  THE THIGH.

    The limb is  to be slightly bent, rotated outwards, and placed  on
* See Dublin Journ. of Med. Science, No. xxvii. 
524                      OPERATIONS.
its outside.   An incision, three inches in length, is made through the
integuments and  superficial  fascia, in the track  of the  artery, or
rather in a line corresponding  to  the inner  edge of the sartorius.
The fascia lata having been next divided to nearly the same extent,
the sartorius  presents itself, and may be recognised by the direction
of its fibres downwards and  inwards.   As soon  as this  muscle is
raised, the fascia extending from the adductor muscles to  the vastus
internus is seen, and will require to be carefully divided, for the pur-
pose  of exposing the sheath of the femoral vessels.
  For the purpose of more certainly  avoiding the vena saphena
major, Mr. Copland Hutchinson,  and M. Roux,  are advocates for
making the incision on the outer side of  the sartorius, which  is to
be pushed inwards.  This  is not, however, the common practice.
The arterial sheath  is opened, and the ligature applied, according to
rules  already given.

           LIGATURE OF THE POPLITEAL ARTERY.

  The patient is to lie  upon his face with the  leg  moderately ex-
tended.   When the lower portion of the vessel is to be secured, an in-
cision, three  inches long, is made  in  the  median  line of the  limb,
through the skin and subcutaneous fat and cellular tissue, care  be-
ing  taken  to push the external  saphaenal vein outwards, if it should
present itself.  After the fascia has been divided,  some surgeons
lay  down  the knife, and,  having  separated the cellular  tissue  and
fat with a director, and likewise  the  head of the  gastrocnemius,
take up the  artery with  the precaution of detaching  it from  the
nerve and the vein with the director.

                    ABOVE  THE  CONDYLES.

  Here the external saphaenal vein  may be  more  easily avoided.
The incision should be longer, and rather nearer the inner, than the
external margin of  the ham,  at least above; and it  should descend
in a slightly oblique direction to the  point over  the  space between
the  condyles.   Under the fascia is the nerve; more  deeply  and in-
wardly lies the popliteal  vein; and quite towards the  bone,  and on
the  inner side of the vein, rather under it, the artery; which is gen-
erally separated  with difficulty from the latter.   In the  instance of
a sloughing ill-conditioned wound,  attended with hemorrhage from
the  posterior tibial artery,  however, where I  had occasion to tie
the  popliteal  artery in University College  Hospital,  the vein, which
was soon  recognised by  its dark  blue color, did  not occasion  any
difficulty in getting  the ligature  round  the artery, and the operation,
which was completed with the utmost facility, did  not occupy more
than three or four  minutes.  As Dr. Duncan of  Edinburgh,  Mr.
Chandler  of Rotherhithe, the two house-surgeons,  Mr.  Wallace, 
DIVISION OF  TENDONS.
525
and others, well know there  was none of the trouble experienced
which has, somewhere or another, been very erroneously described.
What is of more importance, the operation  put  a permanent stop
to the hemorrhage.   In this case, the fact of an  artery not convey-
ing the  slightest sensation of throbbing, when exposed, and  touch-
ed, was most unequivocally exemplified.

 DIVISION OF TENDONS FOR  THE  CURE  OF CLUB-FOOT,  AND
                     OTHER DEFORMITIES.

   Synonymously with the  term " club-foot," Dr.  Little employs
the word talipes, as a generic term to embrace all those  deformities
of the feet, which  arise from the contracted state of certain mus-
cles; and he uses the terms varus, valgus, and equinus, to  desig-
nate the specific forms of such  deformities.
   The least complex is the talipes equinus, which consists in  a
simple extension of the foot, by which the heel is elevated, and the
patient rests  upon the toes and metatarsal bones, no part of the sole
behind  the latter touching the  ground.   By the habitual  disuse of
the limb, the full developement of its bones is  impeded, and  its
muscles are small and flaccid.
   The most frequent of these deformities is the talipes varus, com-
bining extension with adduction of the foot; and, to  these charac-
teristics, a third may be added, viz.  a rotation of the foot,  some-
what analogous to supination of tbe hand, in a greater or lesser de-
gree, according to the severity  of the disease.   The  inner edge of
the foot is thus raised from the  ground, forcing the sufferer to walk
entirely on the outer margin.
   In the talipes valgus, which is  comparatively rare,  there is  a
 partial  bending of the ankle, with abduction and a rotation  of the
foot, by which the outer  edge of the sole is raised from  the ground.
 In a complete case, the  patient treads  entirely upon the inside of
the instep, and upon the malleolus internus.*
   Passing over the palliative treatment by means of  friction, sham-
 pooning, electricity, the moxa,  &c. applicable to some cases, it is
 certain that  all these varieties of deformity may, and frequently do,
 require the knife.   In most  cases of talipes equinus, the section of the
 tendon of Achilles  will restore  the foot to its proper position. For
 this purpose Dr.  Little prefers a small,  curved, sharp-pointed bis-
 toury, with  a  concave edge, the cutting part of the blade  being
 seven tenths of an  inch in  length, and the greatest width one tenth,
 in order that the external puncture may be small.  The patient be-
 ing seated, an assistant supports the knee,  whilst another, drawing
 down the patient's heel with his left hand, and pressing upwards the
  * See a Treatise on the Nature of Club-foot, and Analogous Distortions, by W. J.
Little, M. D. 8to. Lond. 1839. 
526
OPERATIONS.
toes and front of the foot with his right, produces the necessary de-
gree of tension in the tendon  about to be divided.   The bistoury is
passed  through  the skin,  one or two fingers'  breadth  above ihe
malleolus internus, with one of its sides turned towards the tendon,
and the other forwards.  As soon as the point has passed beyond
the external edge of the tendon, and nearly reached the skin of the
opposite side, the knife is turned, so as to bring its edge against the
anterior surface of the tendon, which is  then  divided by withdraw-
ing the knife, and usually at one stroke.*
   It is a matter of  importance to let the external wound be small;
and hence some operators use a sharp-edged needle.   If a  tendon
be cut, and  an extensive division of  the skin over it be made, sup-
puration is likely  to ensue; and,  if  tbis  be protracted, a portion of
the tendon may either slough, or become  adherent to the  integu-
ments, so as to render the operation more or less a failure.   The
healing process should not  be disturbed by premature attempts  to
extend the limb.   The wound should  be closed before extension is
commenced; and, for this purpose, two or three  days  are generally
sufficient.    During this period, the  limb may be laid on  its outside
on a pasteboard splint.   The flexion of the foot  is to  be maintain-
ed with mechanical means.  One of  the most simple contrivances is
a band, or  strap, extending  from the point of the shoe to the fore
part of another  band, or  strap, placed round the limb above  the
knee.   But various means  are  preferred by different operators.
In some obstinate cases of talipes equinus, Dr.  Little has found it
necessary to divide the tendons of the tibialis posticus and flexor
longus pollicis.
   The treatment of talipes varus consists in dividing  the tendon of
the gastrocnemius;  and, if the case be of long standing, it may also
be requisite to cut the  tendons of the  tibialis  anticus, and  tibialus
posticus, when the  extensor and flexor proprius  pollicis, as exem-
plified in cases recorded by Dr.  Little.
   In the talipes valgus, Dr. Little  refers  the deformity  chiefly to
the peronei  muscles; though it  is  usually necessary to divide also
the tendo Achillis,  and even the tendon of the tibialis anticus, be-
fore the foot can  be restored to its natural  position.
   Stromeyer, by means of a small  boot, with a long spring operat-
ing in  a direction opposed to the abnormal eversion,  succeeded in
a few months in curing a talipes valgus in a very  young infant.
   The youngest  patient, in whom Dr. Stromeyer divided the tendo
Achillis for  talipes varus, was eight months old.   Dr. Little  ope-
rated on one child of twenty months;  and Mr. Whipple on another
aged fourteen months.   With regard  to  the other  extreme, Dr.
Little  narrates a  case, (No.  xxxiv. p. 258.) of non-congenital dis-
tortion from  contraction  of the gastrocnemii and other  muscles,
* Little, Op. cit. p. 30. 
STRABISMUS.
527
converted by exercise  into a deformity,  resembling talipes varus:
the cure was accomplished by dividing  the tendo Achillis,  though
the disease  had existed forty-eight years.
   Just as I was closing this volume,  I had a consultation with Dr.
Little on a gentleman, who, in consequence of an extensive necro-
sis of the tibia, now cured, for which I formerly attended him,  with
Mr. Earle, is unable to bring his heel to the ground.   The patient,
who was referred to us for an opinion by Mr. Wood, of Rochdale,
Lancashire, after having long had recourse to mechanical contri-
vances in vain, has been recommended to try what benefit will result
from the division of the tendo  Achillis.   As the case, on account
of its origin from the effects of necrosis, is very interesting, I  trust
that Mr. Wood  will  take an  opportunity of letting the profession
hear the result of the proposed treatment.*

                            STRABISMUS.

   [Strabismus, or squinting, is a loss of the proper parallelism of the
 eyes, so that the two do not act in harmony in vision.
   The affected eye may turn inward, and then it is denominated  stra-
 bismus convergens; or it  may turn outward,  when it is  called diver-
gens : these are the two most  common deformities.  At times,  how-
 ever, both of the eyes are  turned inward, and then we have  what has
 been called double convergens.  Now and then, cases are met with, in
 which the affected organ  is thrown upward, or downward,  from the
 parallelism.
   The divergent form of  squinting is very rare, when compared with
 the convirgent.  Mr.  Duffin reports to have seen only three cases of
 divergens, in upwards of  four hundred.   Mr. Estler of Bristol  men-
 tions to have seen,  in one hundred cases, ninety-two of convergens,
 and eight of divergens.  Mr. R. C. Hall,  of  Manchester, operated on
 two hundred cases,  thirty-two of which were divergens.   My own ex-
 perience would lead me to say,  that this variety is not met with often-
 er, than five or six times in a hundred cases.
   It is difficult to assign any positive reason for the more frequent oc-
 currence of the convergent form of the disease.   The internal rectus
 is somewhat larger than the external, and  this last has a  nerve distinct
 from that of either of  tbe other recti.   The sixth pair  of nerves, or
 abducentes, have their origin just below the pons varolii, and may on
 that account, be more exposed to any influence, produced by fluctua-
 tions in the actions  of the vascular system, and thus  be the cause of
 weakness in the external rectus.
   In nearly  all cases of squinting, there is some impairment of vision.
  * The reader should consult, in addition .to Dr. Little's valuable work, Bietrage zur
Operativen Orthopadik.  8vo. Hanover, 1838.  Whipple, Lond. Med. Gazette, vol.
xx. p. 826, who differs from Stromeyer and  Dr. Little in having recourse  to flexion
of the foot, directly after the tendon has been cut.  M. Bouvier, Mem. sur la Section
du Tendon d'Achille, &c. 4to. Paris, 1838.   Also a judicious account of the subject
in British and Foreign Med. Review, No. 16, art. 5. 
528
OPERATIONS.
Whenever the sound eye is closed, the other will come into its proper
axis, but the patient cannot see as well  as with the other; though  I
have found  in several instances, that after using the  squint eye stead-
ily for a time, it would  recover  its  power, and  the strength  of the
other would decrease from want of exercise.   Sometimes one  eye is
permanenily fixed, while the other turns to take in  objects within its
field of vision ;  then we have what has  been termed luscitas.
  It has been stated, that the disparity in the power  of the. two eyes
was the cause of Strabismus, the mind  taking cognizance of the im-
pressions upon one  eye only, and the other turning aside, that it may
not interfere and produce confusion.  I doubt the correctness of this
opinion, believing the deficiency of power to he the effect, rather than
a cause, of  the squinting.  The  deformity  comes on very suddenly,
as a general thing;  whereas if it depended upon  previous  weakness,
it ought to make its appearance more gradually.  The Strabismus may
be single or it may  be double,  and varies much in degree, and often
when both eyes  are concerned, the patient is very near sighted.  Com-
monly,  when  both  eyes are affected, the vision of  one eye is  better
than the other:  this however is not always so.  In a recent case, the
patient  complains of double vision, but  this passes away in a few days.
Squinting though generally permanent, is at times  temporary, espe-
cially  in  children  who   are  suffering from  abdominal  irritation.
Drunkenness, will also produce a temporary variation in  the  parallel-
ism of the two eyes.
  The causes of squinting  are  numerous,  such as congestion  of the
brain, and convulsions;  hydrocephalus; blows upon the head ; irrita-
tion in the alimentary canal, from dentition or indigestible substances.
Rubeola,  variola, and  scarlatina, are  often followed by strabismus.
Pertussis is  often accounted a  cause of  this deformity, and inflamma-
tion of  the eye itself may produce it.   Children are  believed to  pro-
duce the difficulty,  by imitating the deformity in others, or by looking
steadily at the tip of the nose, or at a patch or scar.
  As to the condition of the muscles, the proper  balance of power is
lost between the internal and exlernal recti : still, except in a  very few
cases, there is no paralysis of  the latter.  This is demonstrated by the
success of the operation, for if there were paralysis,  the cutting of the
contracted muscle,  would avail nothing;  for the  eye would remain
stationary.  Again  if we cover the sound eye,  the other will pass  at
once into the direct axis of the orbit, and move in  obedience to the
will, in order to observe objects in any position.
  In a few of the cases of divergens which I have seen, the  difficulty
depended upon loss of power, or paralysis of  the adductor  muscle;
while in all the cases of convergens, the deformity seemed to arise
from an undue couiraction of the internal rectus.
  Before proceeding to the proper  treatment in these cases, nothing
can be more essential, than that the  anatomy, exterior to the globe  of
the eye, be well understood.    We first notice the  conjunctiva ;  and
this, when the  strabismus  is of long  standing, has  adapted  itself  to
the position of the  eye :  and  that of itself when the  convergence is
strong, will prevent the eye from reaching the direct axis of the orbit.
Below this  membrane  is the sub-conjunctival fascia, which  is  less 
STRABISMUS.
529
yielding than the conjunctiva.   Beneath these two layers are the mus-
cles, included in a fascia, which stretches over both their  orbital  and
ocular surfaces, and extends so as to  form  a firm membrane between
their margins.  In this way we have a firm coat, composed of muscles
and fasciae, which extends from  a few lines behind the cornea,  and
stretches backward so as to cover most of the globe of the eye.   Be-
tween this musculo-fascial layer, and  the  sclerotic tunic, is another
thin fascial lamina, which comes up in that anatomy of the eye which
is concerned in the treatment of strabismus.
  When we come to the treatment in a case of strabismus, it is abso-
lutely necessary that we comprehend its nature, and the cause upon
which it depends.  If there be paralysis of one of the muscles, which
may be ascertained by covering the well eye, and observing whether
there be  motion of the other, in obedience to the  will;  we can  an-
ticipate but little good from an operation-   If the squinting be recent,
and connected with some temporary abdominal irritation, some undue
fulness of the vessels of the brain, or some  strong mental excitement,
we have  only to attend  to the exciting cause, and probably when  that
is removed,  the eye will assume its normal  position.  Sometimes we
meet with cases of strabismus, which have  arisen from some  opacity
of the cornea, resulting from inflammation, and  where the change in
the position of the eye,  has been for the purpose of admitting light to
the retina.  In such a case an operation is to be deprecated.  Again
when an eye is  amaurotic, it often  assumes  an abnormal  position:
when such is the case nothing will be gained by  an operation.
  An operation is  indicated, then, when the strabismus depends upon
a loss of balance between, and not on a loss of power in, the muscles ;
and when the squint eye, (the sound one  being covered,)  moves in
accordance with the will.  In  such  a case we can promise much to
the patient, if the  operation be carefully and  judiciously performed.
Soon  after the  introduction of the operation, many who dared not
touch a knife on other occasions, sought out cases  and operated for
squinting.  The result has been that very considerable injury  has
been done to patients, and much discredit brought upon the operation.
It is one  of the most beautiful operations in surgery, and there is none
more successful, or more happy in its result, when  the case  is proper-
ly selected, and the operation is understanding^ performed.  It ob-
viates a very  striking and  unpleasant deformity, and gives the patient
another eye/or use.  It is one of the triumphs of modern surgery.
  Before proceeding to  the details of the operation, I would mention
that it was first suggested by Dr.  Stromeyer of Hanover, the pioneer
in the operation for talipes, in 1838; but that to Prof. Dieffenbach, of
Berlin, belongs the honor of having first performed  it. This was done
by him in 1S40.  The same year, the operation was repeatedly  per-
formed in England, France,  and America.
  There are  several  methods of operation  laid down by different  sur-
geons, depending upon the instruments employed, the position of  the
patient, or the manner in which the parts are cut.  With these meth-
ods we have connected  the names of Dieffenbach, Ammon Liston,
Guthrie, Lucas Velpeau, Ouerin, Gross, Paucoast, Port, &c.   Each
  vol.  n.                   45 
530
OPERATIONS.
 of  these gentlemen claims a preference for his own operation,  as we
 should  expect;  still there is not much  choice among  them; some
 adopt a more,  and some a  less complicated  procedure.   My own
 preferences are always in favor of the more simple course.   In order
 to  perform the operation,  we  require three  instruments :  a pair of
 delicate pointed  thumb  forceps, a pair of small scissors, (it matters
 but little whether  they be straight, or curved on the side or edge,
 blunt, or  pointed,) and a blunt hook to pass  under the muscle.   We
 require one assistant, if  the patient be an adult, and two, if it be a
 child.  The patient may either sit or lie as is  most agreeable.  If it
 be  a child we are about  to operate  upon, he must  be held firmly in
 the lap, the hands being secured-  An assistant supports  the head,
 and at the same time separates the palpebral.   The well eye may, or
 may not be covered, it matters but little.  The operator  now takes
 his thumb-forceps and scissors in hand, and  while the patient turns
 the eye outward as  far as he well can, he  seizes the conjunctiva one
 line outward from the caruncula,  this enables  him to hold the eye
 steady,  while with the scissors  he makes  an opening in  the conjunc-
 tiva, in  a vertical direction, about three quarters of an inch long.  He
 then lays his scissors one side, still retaining his hold with the forceps,
 and takes up the blunt  hook, which he introduces from below  up-
 ward, under the muscle ;  when the muscle is secured upon the hook,
 the forceps are dispensed with, and the scissors again  taken  in hand,
 and the muscle freely divided.   The steps of  the operation are, prop-
 erly speaking, four  :  First, the seizure of the conjunctiva with  the
 forceps, so as to  control the eye ;  Second,  the cutting of the con-
junctiva with  the scissors;   Third,  the   introduction of the blunt
 hook ;  And fourth, the  division of the muscle.
  When the operation is completed  according to the  above process,
 it rarely happens that the eye at once resumes its proper parallel axis.
 It will be found necessary to carry the incision further.  A few  fila-
 ments of the muscle being left, they  will  turn the eye in, and defeat
 the operation.   The blunt hook  must be introduced  again, and the
 remainder of the muscle cut.   When  it is entirely divided, the scle-
 rotic tunic can be distinctly seen,  and  beside, if the fibres are all di-
vided, the patient will have no power  to turn the eye strongly inward
 toward  the nose.  Notwithstanding  all this, the eye sometimes does
not assume its proper parallelism; then the operator should  proceed
to divide the conjunctiva and fascise, upward and downward, two linea
distant from the cornea, and when these  membranes, which are too
short to allow the organ  to turn outward sufficiently far, are divided,
the eye  will assume its  proper position.   We  cannot exercise  too
much care in this last part of the operation.   We should divide  but
a little at a time, for there is danger  of  inducing the strabismus di-
vergens, which is worse than the  convergens.  There is another diffi-
culty which sometimes occurs, if we  are  incautious, and divide the
conjunctiva and  its  fascia too far; the eye suddenly  protrudes  and
causes a bad deformity.
  I have often operated and divided the muscles, and other parts,  and
still the  eye did not turn out  sufficiently.   By directing the patient 
STRABISMUS.                       531
to accustom himself  to turn the eye outward  as  far  as  possible
from time to time, in a few days I have had the satisfaction of seeing
the organ brought to its proper parallel axis ;  probably in consequence
of the increase of power in the external rectus, from diminishing the
over extension of the  muscle, and from the exercise.  I have never
found it necessary to divide either of the oblique muscles.
   When we have operated, we sometimes find  the eye slightly diver-
gent.  Our patient should then be directed to look inward, instead of
outward, and we may calculate, that the contraction from cicatriza-
tion, will restore the organ to a right position.
   It often  happens after an operation, that  the  patient complains of
double vision.   We may give every assurance, that it will  pass away
in a few days.
   There is generally but little after treatment required.   I advise that
the eye be not exposed to strong  light, and  that it be kept  wet with
cold water;  and rarely, very rarely, have I  had  any  inconvenience
from inflammation.  Frequently after the lapse of two or three weeks,
the patient will  call our attention to a fungus in the inner canthus:
this should  be removed with the  scissors, and  the part touched with
the nitrate of silver, and nothing more will be required.
   There is another mode of operation  which is called  the sub-con-
junctival, which was introduced by Guerin.   It will do  to talk  about,
but I am confident it can never succeed in practice.  The operation
is simple, the muscle can be  divided, but there  will still be  left  the
conjunctiva  and the fasciae, which will  retain the  eye inward,  and
certainly defeat the object of the operation.
   There is  also another objection to the sub-conjunctival method,  it
often permits a troublesome amount of extravasated blood.—Ed.]
THE END. 
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